U.S. guidelines advise early action against hypertension—here’s why that might not be a good idea

Contrary to U.S. guidelines, early action against high BP in patients exhibiting signs of hypertension doesn’t reduce their risk of heart disease later in life, according to a study published in the European Heart Journal Nov. 21. In fact, it could actually contribute to more cases of depression and poorer mental health.

The study, headed by professor Karl-Heinz Ladwig and a team from the Technical University of Munich and Helmholtz Zentrum München, explored the American College of Cardiology’s latest BP guidelines, which were updated in 2017 to include a new category: stage 1 hypertension.

Under the new U.S. standards, cardiologists are advised to diagnose patients with “stage 1 hypertension” upon presentation if they record blood pressure in the 130-139 mmHg/80-89 mmHg range. Ladwig and co-authors said that in Europe, those numbers translate to “high normal” blood pressure—BP that’s on the upper end of the spectrum but doesn’t pose any immediate threat to the patient or require specific action.

“The idea behind the U.S. guidelines is to lower blood pressure as early as possible and, by presenting patients with a diagnosis, to encourage them to adopt a healthier lifestyle,” Ladwig said in a release.

But he also said that line of thinking is flawed, since a lower threshold for hypertension means more diagnoses, more sick people and, ultimately, more mental distress.

Ladwig and his team assessed the situation in Germany in a representative sample of 11,603 middle-aged residents enrolled in the MONICA/KORA database. In that population, which was 48 percent women, the new ACC guideline increased the instance of hypertension from 34 percent to 63 percent.

The cut-off for stage 2 hypertension in America is currently anything over 140/90 mmHg, and U.S. and European guidelines alike agree patients should initiate antihypertensive treatment at that point. According to Ladwig et al.’s research, just 24 percent of stage 2 hypertension patients in their study were actually under treatment, and within a decade 370 died from fatal CVD events.

The authors said patients who exhibited symptoms in line with stage 1 hypertension didn’t differ much in CVD mortality risk from those with normal blood pressure. Stage 2 patients were, predictably, at a higher risk for death from CVD, but it was in these patients that Ladwig and colleagues found the most fault in the ACC’s new recommendations.

“The motivation effect is questionable,” Ladwig said. “Risk factors such as smoking and a lack of exercise are far more frequent in that group. That shows that many people do not change their lifestyle despite the diagnosis.”

The finding directly contradicted the ACC’s line of thinking—that if patients are diagnosed earlier, they’ll take action earlier. But Ladwig said people are more likely to interpret an early diagnosis negatively, affecting their mental health and effectively barring them from taking steps to mitigate their condition. What’s more, early uptake of a prescription drug routine could trigger depression in those patients.

Because of that, and since stage 1 patients were hardly at an increased risk compared to the general population, the authors said it would be a mistake to adopt the ACC’s latest guideline in Europe.

“We believe that [it] should be seen as a labeling effect,” Ladwig said. “When people are officially labeled as ‘sick,’ that has an impact on their mental health.

“The American College of Cardiology itself has calculated that the proportion of adults diagnosed with high blood pressure will increase from 32 [percent] to 46 percent. That means 14 percent more who have to deal with the additional mental stress, although their risk of developing a potentially deadly cardiovascular condition is not significantly higher and despite no real expectation of extra motivation through the diagnosis.”