Intended for healthcare professionals

Letters Overtreating mild hypertension

Historical footnote on the treatment of mild hypertension

BMJ 2012; 345 doi: (Published 24 September 2012) Cite this as: BMJ 2012;345:e6297
  1. Julian Tudor Hart, retired general practitioner and honorary research fellow1
  1. 1University of Wales Swansea Medical School, Swansea SA3 2HH, UK
  1. juliantudorhart{at}

The Cochrane review of randomised trials of treatment for “mild” hypertension, which found no benefit in drug treatment, prompts two important questions.1 Why has it taken more than 30 years to reach a conclusion that was evident from critical reading of the original trials that claimed to justify interventions in the diastolic range 90-100 mm Hg? And how can we get practice on to a more rational footing?

In 1983 I was invited to a symposium organised by the World Health Organization—but sponsored by Merck Sharp and Dohme, Ciba-Geigy, and Sandoz—to consider available evidence on treatment for hypertension in the diastolic range 90-100 mm Hg.2

Before the conference a letter went to all participants from Austin Doyle, who had led the Australian National Blood Pressure Study.3 Together with the poorly controlled Hypertension Detection and Follow-up Program,4 this was all the evidence available, but he asked us, before the conference, to sign a joint statement recommending intervention from the 90 mm Hg threshold. Because the conference’s aim was to consider evidence before reaching any conclusion, I refused. I was the only general practitioner there and I was appealed to reconsider, because everyone else had signed. I still refused, so before the first session I was invited to a meeting, chaired by Doyle, together with a dozen big figures from the international world of hypertension research, to put my case. Doyle replied, “Fuck the MRC trial. Do we always have to wait for the fucking British?”

Bill Miall, who led that trial, was sitting next to me. He advised me to sign the document like everyone else, which I did. I thought I had reached the limit of what a mere GP could do without becoming hopelessly isolated. In a letter to the Lancet a few weeks later Bill withdrew his signature, on the grounds that it might compromise the then still unpublished conclusions of the MRC trial. Even when those came, I stuck to my guns in all three editions of my book on community control of high blood pressure, unconvinced by subsequent trials that intervention was justified at this level for people without diabetes or organ damage.5 Ho hum.


Cite this as: BMJ 2012;345: e6297



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