VoL. 8, No. 19 Ocroser 1, 1972

 

edicine

An Independent Newspaper for Physicians

 

hypertension Control
FE fforts Seen Minimal

By Allen J. Seeber
WASHINGTON—Neither physicians nor
their patients are paying an adequate
amount of attention to hypertension,
though its complications have a sub-
stantial mortality rate, a Veterans
Administration investigator has re-
ported.

In a monograph scheduled for pub-
lication next month, Dr. Edward D.
Freis warned that “only about 50 per
cent of patients know they have hyper-
tension.”

Dr. Freis, senior medical! investiga-
tor at the VA hospital here who has
been repeatedly honored for his work
on hypertension, wrote that a survey
of large businesses in Chicago dis-
closed that “only 11 per cent of pa-
tients were receiving effective treat-
ment” for the condition.

(Continued on page 12)

 

—U.S. Medicine photo
Dr. Edward D. Freis
12.

U.S. MEDICINE

 

Hypertension Control Efforts
Seen Minimal By VA Investigator

(Continued from page 1)

The major reason for this “sad
state of affairs,” he said, is that “the
bulk of physicians have remained un-
convinced that the treatment of hyper-
tension justifies the associated side
effects, expense, and inconvenience.
There is also a highly prevalent notion
that hypertension does not require
continuous surveillance or control.”

Moreover, he said, hypertensive pa-
tients “feel well until major com-
plications develop.”

“It is difficult to convince them that
they need to take daily medications
which may, for a time at least, make
them feel less well than they were
before.

But it is “one of the most ubiquitous
of diseases,” he said. There are ap-
proximately 23 million persons with
blood pressures in excess of 150
systolic or a disatolic of 95 mm Hg or
higher.

Added to the problem, however, is
the “therapeutic nihilism” which has
characterized medical tradition with
respect to benign essential hyper-
tension, he commented.

Dr. Freis explained that the word
“benign” was often “taken literally
nor was it conceded that antihyper-
tensive drug treatment could prevent
the development of cardiovascular
complication.”

He pointed out that “because of the
great emphasis on coronary heart dis-
ease and stroke in recent years it is
generally overlooked that congestive
heart failure is an important cause of

disability and death and that hyperten-
sion is by far the principle culprit in
its pathogenesis.”

The response has been to place “en-
tirely too much emphasis” on iden-
tification and treatment of curable
forms of hypertension, he added. But
the “impact of extensive diagnostic
work-up of patients for curable hyper-
tension on reducing morbidity and
mortality in the general hypertensive
population has been minimal.”

“The true prevalence of curable
hypertension in the total population of
hypertension patients probably is less
than 5 per cent and may well be as
small as 1 per cent,” he said.

“The routine application of an elab-
orate, time consuming and expensive
work-up for curable forms of hyper-
tension in every patient is an example
of poor medical judgment.

“The search for curable hyperten-
sion should be individualized, princi-
pally to patients below age 35, those
above this age who fail to respond to
medical treatment, those who have had
a recent increase in the severity of
their hypertension or those who give a
suggestive history such as paroxysmal
hypertension.”

Dr. Freis said the important factors
“which govern the degree of risk of
developing cardiovascular complica-
tions of hypertension are the height of
the blood pressure, the persistence
of the elevation of blood pressure, the
family history of hypertension and car-
diovascular-renal complications sec-
ondary to it and the degree of target-

organ damage (fundi, brain, heart and
kidney) already present.”

“Unfortunately, medical tradition
has grossly exaggerated the impor-
tance of detecting curable hyperten-
sion,” he continued.

“For years physicians have been
taught that their major obligation was
to rule out curable hypertension, and
once this was done, their obligation
to the patient had been discharged. The
devastation of human lives that has
resulted from this erroneous teaching
can hardly be overestimated,” he
said.

“The physician’s responsibility only
begins with the ruling out of curable
hypertension and he must not strain
unduly his own or the patient’s re-
sources in doing so.

“The problem is to restore a per-
spective which is consonant with the
relative worth of diagnostic and ther-
apeutic procedures that are most apt
to be effective in preventing the major
complications of hypertension.

“The greatest cost-benefit ratio lies
in the treatment, specifically in the
drug treatment of hypertension,” he
said.