TARGET OF THE YEAR:

w . Walter Jones, a dermatologist in a large Midwest city, shares a medical problem
  with 23 million other Americans: He has hypertension. In addition, Dr. Jones (this is
not his real name) has had a complication that fortunately does not afflict most of his fellow
hypertensives, although it could happen to some of them. He suffered the distressing ef-
fects of hypertensive encephalopathy.

Twenty-five years ago, when he was a medical student, Walter Jones was diagnosed as
having hypertension. But in those days there were no effective drugs in general use for
treatment. For decades he had no symptoms, although his diastolic pressure ranged be-
tween 110 mm Hg and 120 mm Hg. During those years, Dr. Jones was worked up by a
dozen or more internists, friends of his who were teaching at the three medical schools in
his city. All of them diagnosed his hypertension, but none treated him, not even after effec-
tive medications had become available.
On a vacation trip last year, Dr. Jones suddenly developed symptoms of hypertensive en-
cephalopathy. A leading cardiologist found that his diastolic pressure was 150 mm Hg.
Then Dr. Jones finally received a pre-
scription.

He went home and resumed his
busy practice. During the next weeks
the medication brought his pressure
down, so he decided to try getting
along without a chemical crutch.
Within a short time, he had a stroke
that caused cerebral deterioration. He
is now back on medication, his blood
pressure is down to 140/90 mm Hg,
but the brain damage is irreversible.
Hard to believe? How could it hap-
pen to a physician? Dr. Jones' experi-
ence points up a continuing medical
problem: Many physicians who recog-
nize that drug therapy is beneficial in
malignant or other severe or moder-
ately severe hypertension do not be-
lieve in treating the much more com-
mon mild or moderate forms of the
disease. Their belief has been an-
chored in tradition and sustained by
the fact that, until recently, there was
no proof that antihypertensive agents
                           continued

In Washington, D.C., paramedics make
  prescheduled home visits to identify
hypertensives. Uponjinding a candidate
(right), they escort her to bus for ride
to Georgetown clinic and further tests.

MEDICAL WORLD NEWS/August 24, 1973


HYPERTENSION contrnued

could reduce morbidity and mortality rates. Since most
patients with essential hypertension, which affects at
least 85% of those with elevated pressure, are asympto-
matic, doctors have often been loath to put them on life-
long medication that might produce side effects such as
potassium depletion, gastrointestinal disturbances, tired-
ness, depression, or impotence.

Nor, in recent years, have patients been flooding doc-
tors' offices, clamoring to have their hypertension diag-
nosed and treated. In fact, of the estimated 23 million hy-
pertensives in the U.S., only about half are aware of their
condition, and only 10% to 29% are receiving effective
treatment. Public ignorance and professional passivity
have long combined to produce inaction against the dis-
ease that the American Heart Association says "probably
represents the major health care challenge in the country
today." Some physicians even refuse to tell patients that
they have slightly elevated pressures, feeling that the re-
sulting alarm is the surest way to cause hypertension.

Indeed, hypertension may be the nation's leading cause
of death. Along with being responsible for the 60,000
deaths attributed each year to high blood pressure and hy-
pertensive heart disease, it is a major underlying factor in
the annual total of more than one million deaths from car-
diovascular disease and strokes. The direct and indirect
yearly cost to the nation was estimated at about $5 billion
in 196'7, and it is certainly higher now.

Dr. Edward F. Freis, senior medical investigator of the
VA, places chief blame for the toll on "the bulk of physi-
cians who have remained unconvinced that the treatment
of hypertension justifies the associated side effects, ex-
pense, and inconvenience." He also criticizes the tendency
to put too much emphasis on curable forms of hyperten-
sion such as the renovascular type and those associated
with pheochromocytoma, Cushing's syndrome, and certain
other conditions, all of which account for less than 5% of
the hypertensive population.

Another leading clinical investigator, Dr. John H.
Laragh of Columbia University, says, Yt's hard to change
a doctor's mind when he's seen hypertensive patients for
years, and nothing happened to them. What physicians
are doing is falling back on their own gut feelings. There
are patients with high blood pressure who live to a ripe old
age. But every statistical study shows that hypertensives
as a group don't live as long as normotensives, and they
get strokes and heart attacks at a much faster rate."

Dr. Freis, in particular, has grounds for chiding col-
leagues, for it was he who nailed down the proof, in re-
ports published in 1967 and 1970, that antihypertensive
drugs can ward off complications and lengthen life. The
classic VA cooperative study directed by Dr. Freis demon-
strated that, in male patients with diastolic pressures of
105 mm Hg or higher, the risk of developing cardiovascu-
lar, cerebrovascular, or renal complications over a five-
year period was reduced by a ratio of more than three to
one by treatment, and deaths were also cut. For this work,
Dr. Freis received the Lasker award in 1971.

The award marked a turning point. It brought into the
fight against hypertension Mrs. Mary Lasker, president of
the Albert and Mary Lasker Foundation, who in Washing-

New screening approaches include having blood
pressure taken by (from left) a de,ntal assistant,
a high school student trained to make home visits.
and a medical secretary using ultrasonic device.

ton bureaucratic battles has won victories for countless
health causes. With her Washington chief of staff, Michael
Gorman, director of the National Committee Against
Mental Illness, Mrs. Lasker successfully laid siege to Elliot
L. Richardson, then Secretary of HEW.

In July 1972, Secretary Richardson, acting on recom-
mendations made by a conference of government and
nongovernment agencies, launched the National High
Blood Pressure Program-a campaign that is beginning to
have great impact across the country this year. First he
appointed two committees, the Hypertension Information
and Education Advisory Committee and the Inter-Agency
Working Group on High Blood Pressure. The latter
brought together representatives of the NIH, the Health
Services Administration, the FDA, and the VA. NIH was
given the job of coordinating the program through the
National Heart and Lung Institute (NHLI). Task forces
were organized to make recommendations on criteria for
screening, referral, and treatment; on educational pro-
grams for health professionals and for the public; and on
resources required to carry out the program.

The campaign gained added momentum at a National
Conference on High Blood Pressure Education, sponsored
by HEW last January. By this time, the National High
Blood Pressure Program had undergone a slight but sig-
nificant semantic transmutation-its name was changed

70


to the National High Blood Pressure Education Program
(NHBPEP). A special information center was set up
within NHLI, and the program was given a $2-million
budget. At about the same time, Citizens for the Treat-
ment of High Blood Pressure, Inc., came into being, with a
former Richardson aide, Thomas P. Reutershan, as direc-
tor, and Mrs. Lasker and Gorman on the board.

In his keynote address at the January conference, the
then-HEW Secretary Richardson defined the federal gov-
ernment's role as that of a catalyst to spark the spread of
information. The national program leans heavily on the
initiative of individual physicians and medical organiza-
tions as well as hospitals, medical centers, pharmaceutical
companies, industrial firms, and community groups. It
also expects considerable help from the American Heart
Association, which has made hypertension its first priority
for the next three years and summoned its chapters and
affiliates to provide troops for a far-reaching campaign.

A special AMA committee headed by Dr. Morton D.
Bogdonoff, chairman of medicine at the University of Il-
linois and editor of the Archives of Internal Medicine, has
recommended "prompt and vigorous therapy of hyperten-
sive patients." Moreover, the committee urges "all physi-
cians, irrespective of specialty, to routinely measure the
blood pressure of every patient initially seeking care for
any complaint." Special emphasis on hypertension is also

MEDICAL WORLD NEWS/August 24, 1973

being planned by the American College of Cardiology
through symposiums for practitioners and editorials and
articles in the American Journal of Cardiology.

Medical schools are being asked to review their curricu-
lums and make certain that future physicians are pre-
pared to treat hypertension. Medical examining boards
are being requested to do the same with their tests.

The man in charge of the national program, Dr. Theo-
dore Cooper, director of NHLI, sees encouraging progress
in the first year. "If you compare the amount of activity in
high blood pressure awareness campaigns, screening ef-
forts, television exposure, and books being published this
year with that of previous years, there is a great differ-
ence. I was watching Channel 5 in Washington the other
day. Several times it showed a spot urging people to have
their blood pressures checked. You didn't see that before,
and it's going on in many parts of the country." In the
fall, millions watching the televised games of the National
Football League will also be seeing spots with a pitch for
having blood pressure measured.

Screening. Making a serious dent in the vast hyperten-
sion problem will obviously require massive efforts to
identify unknowing millions of patients. Small hyperten-
sion screening projects, sometimes included in multiphasic
health exams, have been under way in various communi-
ties for some time. One of the larger programs is the Chi-
                                   continued

71


HYPERTENSION conbnued

cage Heart Association Detection. Project in Industry,
which since 1967 has been screening employees for factors
that increase their risk of coronary heart disease.

With the launching of the NHBPEP, screening has re-
ceived heightened impetus. The most ambitious program
has been sponsored by the Ciba Pharmaceutical Co., in co-
operation with local heart associations and medical so-
cieties. Under the title of Community Hypertension Eval-
uation Clinics (CHEC), the program, started early this
year, has now covered about 80 communities with two or
three-day screenings. The two largest CHEC campaigns
so far were held in New Orleans, where 25,000 were
screened, and in San Diego, where 41,000 were checked.

After being widely publicized in the press and on radio
and TV, the screenings are conducted in shopping centers
or schools (see cover). A few doctors and nurses and a
large number of volunteers, including paramedics, consti-
tute the personnel. People with elevated readings are re-
ferred to their own physicians or to local clinics. Of more
than .125,000 screened so far, about 28% have been re-
ferred. This figure does not mean that one out of every
four people screened has hypertension. Initial readings,
especially under tense circumstances, are sometimes well
above the person's usual range. It is up to the doctor con-
sulted by the patient to determine whether the elevation
is more than transitory. NHLI's Dr. Cooper estimates that
only about half of those referred from screenings turn out
to be confirmed hypertensives. In all communities, physi-
cians are asked to provide feedback about patients who
visit them as a result of the campaign.

"We've been trying to follow up on all 8,102 people who
had high readings at our screening in April," says Dr.
Stanley Garbus, who directed the New Orleans project for
the Louisiana Heart Association. "There has been no
great inundation of doctors and clinics, but we did hear
from quite a few physicians that people who had been re-
ferred were showing up."

The next large CHEC screening is scheduled for Sep-
tember 7 and 8 in Montgomery, Ala. Another is planned in
Baton Rouge, La., October 13 and 14. All told, 110 commu-
nities are expected to be covered this year, and the pro-
gram will continue indefinitely.

Another major project that involves not only screening
but also treatment is the national detection and follow-up
program sponsored by the NHLI in 14 communities: At-
lanta; Baltimore; Evans County, Ga.; Jackson, Miss.;
Lansing, Mich.; Los Angeles; Minneapolis; Salt Lake City;
and Washington, D.C. This will be a five-year study of
10,500 hypertensive men and women, with a high propor-
tion of blacks. Begun in February, it had screened 51,000
people ranging in age from 30 to 69 by the end of June.

Persons with a diastolic pressure over 95 mm Hg, deter-
mined by averaging several readings, are asked to come to
a clinic for a recheck. There, blood pressure is taken six
times, and if it averages above 90 mm Hg, the person is
asked to participate in the program and go through a
thorough physical examination and lab tests. In each com-
munity, the hypertensives are then divided into two
groups. Half are assigned to what is called the stepped-
care program, a systematic treatment plan that starts

72

Dr. Finnerty: `The biggest problems are keeping
people under medical care and gaining compliance.'

Dr. Freis:.`Idon't think it really matters what
works-pills or diet-as long as something does.'

Dr. Laragh: `Re,nin activity levels may provide
a guide to selective and more rational therapy.'


with a single drug-a diuretic-and steps up the therapy if
necessary. The other half are assigned to a community
source of medical care, which could be a patient's own doc-
tor or clinic. The first group are treated at the program's
clinic, and each patient is seen at least every two months
in the first year and later at least every four months. The
second group will be visited annually and will be asked to
come to the clinic for a checkup every two years.

"What we're trying to find out," says Dr. Gerald H.
Payne, NHLI scientific project officer for the study, "is
whether this type of stepped-care treatment results in
any benefit as compared with the mixed therapies that
prevail in the community. We'll look for differences in the
occurrence of enlarged hearts, heart attacks, and strokes,
and in the death rates of the two groups."

Manpower. There are obviously not enough primary
physicians to provide screening, therapy, and follow-up
for all hypertensives or even for a substantial number of
those not now under treatment. However, one untapped
reservoir of potential screeners consists of the many phy-
sician-specialists who do not give primary care. An effort
is being made by the AMA and the Hypertension Infor-
mation and Education Advisory Committee to get all of
them to take their patients' blood pressures routinely and
refer those with elevated readings.

Striking proof that even in hospitals the checking of
blood pressure is often neglected has been provided by a
leading hypertension specialist, Dr. Frank A. Finnerty Jr.
of Georgetown University. He recently had a nurse circu-
late from ward to ward in a large Washington, D.C., city
hospital, taking blood pressures of patients who were not
on the medical or obstetrical services. Of the 1,300 re-
corded pressures, 400 were over 150/100 mm HMG: only
115 of these patients knew they were hypertensive, and
only eight were getting treatment.

Georgetown University and the District of Columbia
Heart Association have now joined in a project to train
high school students wanting summer jobs to measure
blood pressure in hospital clinics where it is not done rou-
tinely. The national program's advisory committee has
proposed that every hospital and patient care institution
make a major commitment to assure that all hyperten-
sives are identified and receive appropriate treatment.

Another untapped reservoir of potential screeners is the
nation's 121,000 dentists and their auxiliary personnel.
The Bergen County, N.J., Dental Society and Fairleigh
Dickinson University School of Dentistry have issued a
brochure urging all dentists to have their assistants take
patients' blood pressures. When the reading is elevated,
the dentist himself is asked to call the patient's doctor.

An expanded role for specially educated nurses has been
proposed by the American Heart Association. These
nurses would "act as primary care practitioners in the
area of hypertension," and would "take the initial history,
follow the therapeutic regimen, and evaluate the progres-
sion of the illness." A trend in this direction is already un-
der way, reports Dr. Finnerty. His own university's'school
of nursing has a new program for educating nurse-spe-
cialists, the first of whom will graduate in 1974. In the
past year, the VA's Dr. Freis in Washington and Dr. Jo-

seph A. Wilber in Atlanta have similarly been training
nurses to operate hypertension clinics.

Also required will be much wider reliance on physicians'
assistants and other paramedics. Increased training of
health aides is high among the recommendations of the
national program's advisory committee. Notable situ-
ations where they are already being used include the am-
bulatory care project at Boston's Beth Israel Hospital, the
Automated Military Outpatient System at Dewitt Army
Hospital, Fort Belvoir, Va., and Dr. Finnerty's hyperten-
sion clinic at D.C. General Hospital.

"The only way we are ever going to handle the huge hy-
pertension problem," says the Washington cardiologist,
"is to have it taken care of largely by paramedical people.
Our clinic in inner-city Washington is paramedically run,
nurse-supervised, and has a doctor for consultation. Each
patient is examined by the doctor the first time and put on
a set program. Once the patient reaches a status-quo situ-
ation, which usually is fairly quickly because most have
mild to moderate disease, he is seen on each following
visit by the same paramedic, who talks about the disease
and educates and motivates the patient." With this ap-
proach and drastically reduced waiting time, Dr. Finnerty
says the clinic's dropout rate has been cut from 42% to 8%.

None of the proposals for using paramedics dispenses
with the doctor as leader of the health care team. It is he
who evaluates and prescribes, and it is he who is consulted
when any problem arises, proponents emphasize.

Blacks. In the 14th century, the black plague devastated
the white population of Europe. In the 20th, hypertension
is the plague of blacks in the U.S. It is unquestionably the
leading cause of death among them. (For every black who
dies of sickle cell disease, 100 die from hypertension.)

Studies indicate that the disease is at least twice as
common among blacks as among whites and tends to be
more severe. The National Health Survey of 1960-1962
found that hypertensive heart disease was three times
more prevalent among black males and more than twice
as frequent among black females as among their white
counterparts. Both hereditary and environmental factors
are thought to be responsible. In the case of American
blacks, most of whose ancestors came from West Africa
where hypertension is widespread, the genetic compo-
nents may be particularly strong.

There is also clear evidence among both blacks and
whites of a familial predisposition. Says cardiologist Ha-
zel M. Swann, chairman of the hypertension commission
of the predominantly black National Medical Association:
"In my family, all women develop hypertension at about
age 45." And she adds with a wry laugh: "I have six years
to go." Dr. Swann, who is director of professional stan-
dards in the Bureau of Community Health in HEW's
Health Services Administration, believes the chief factor
in the prevalence of hypertension among blacks is genetic
but indicts a diet high in salt and fat as a second factor.

Under Dr. Swann's leadership, the NMA is actively par-
ticipating in the NHBPEP with primary emphasis on
"making the campaign relevant to blacks." Two-day
workshops devoted to hypertension preceded the organiza-
tion's annual meeting in New York earlier this month.
                                 continued

MEDICAL WORLD NEWS/August 24, 1973

73


HYPERTENSION continued

Videotapes of the sessions will be made available, to-
gether with visiting consultants, to NMA constituent so-
cieties. Next January, the .NMA plans to hold national
hearings in Washington, D.C., on hypertension among
blacks and send recommendations to the White House.

Diagnosis. Because emotional or environmental factors
can cause blood pressure to fluctuate, most specialists sug-
gest that the average pressure on three successive visits
be the criterion. At what point does hypertension begin?
This is almost like asking how high is "up." The eminent
British authority, Sir George Pickering, argues that there
is no dividing line between normotension and hyperten-
sion. He maintains that high blood pressure is unique in
being a quantitative rather than a qualitative disease. In-
surance company statistics support his thesis in showing
that, even within the so-called normal range, those with a
lower diastolic pressure live longer than those with a

higher one, and the same is true of the systolic pressure.

The "quantitative" concept has not met with universal
acceptance among the experts, however. Columbia's Dr.
Laragh, for one, believes it wipes out the distinction be-
tween normal and abnormal. Moreover, his own studies
show that "essential hypertensives can have an equal de-
gree of high blood pressure, but some have low renin lev-
els, while others have normal and high renin levels. We be-
lieve this means that different mechanisms are at work
and that these three groups of patients are not similar."
They may thus require different management.

In any event, even Sir George suggests a diastolic
level-95 mm Hg in men, 105 mm Hg in women-at which
treatment should begin. The international standard
adopted by WHO has been 160/95 mm Hg. But, in this
country, there has been a trend toward lowering the "di-
viding line" to 140/90 mm Hg.

POSSIBLE MANPOWER SOLUTION: AN ELECTRONIC `COLLEAGUE'

Can a computer be "taught" to diag-
nose and treat hypertension? Dr.
Fredric L. Coe, director of the renal
division at Chicago's Michael Reese
Hospital and Medical Center, is now
conducting an unusual study that he
believes will show that the machine
can do the job as well as a doctor-or
perhaps even better. If he succeeds,
his computerized system should help
to solve the problem of the greatly in-
creased patient load that is expected
to accrue from the National High
Blood Pressure Education program.
Moreover, he believes that the sys-
tem could be operated by para-
medics under physician supervision.

On July 1, Dr. Coe and his associ-
ates, Drs. Suzanne Oparil and
Theodore N. Pullman, began a long-
term study that will compare com-
puter diagnosis and treatment with
the performance of specialists. The
first phase of the study will run until
the end of the year and include about
400 patients, 50% of whom are being
randomly assigned to the computer
and the others to physician manage-
ment. They are being treated at clin-
ics at Michael Reese Hospital and at
the University of Chicago.

At the outset, a physician gives
each patient a physical examination
and orders various laboratory tests.
Blood pressure is measured with an
automatic instrument called the Ar-

teriosonde 1216, which utilizes ul-
trasound and is manufactured by
Hoffmann-LaRoche. Data from the
physical exams, lab tests, and pres-
sure readings of half the patients are
fed into an IBM360-65 computer that
has been intricately programmed to
respond to a great variety of informa-
tion. Within a few minutes, a printout
of recommendations appears. For a
new patient, the computer suggests
two additional visits so that the aver-
age blood pressure can be deter-
mined. When treatment is indicated,
the machine, which is leased on a
part-time basis, recommends a spe-
cific drug and dosage. The data and
recommendations are entered on a
chart that goes to the patient's doc-
tor. He can sign the prescription the
computer printed or rewrite it.

In the present phase of the study,
the computer's pharmacopeia is lim-
ited to the thiazide diuretics (for

which furosemide can be substi-
tuted), methyldopa, hydralazine, and
guanethidine. In a later phase, reser-
pine and propranolol will be added. If
the blood pressure of a patient under
treatment is not controlled after two
visits, the computer will increase the
dosage. When the pressure remains
recalcitrant, the machine will add an-
other drug or suggest a more potent
one. The program relies on nurses to
recognize side effects.

How do doctors feel about compe-
tition from an electronic "col-
league"? So far, the program is
being well accepted by physicians at
both clinics, reports Dr. Coe, who is
associate professor of medicine at
the University of Chicago. He empha-
sizes, however, that the computer
system is experimental and that a
long-term study will be necessary to
determine its feasibility for wide-
spread use.

L%. Coe hopes computer can expedite
patient care at Michael Reese clinic.

74


The VA study included men with diastolic pressures av-
eraging 90 mm Hg or higher. Effectiveness of treatment
was clear-cut in patients with pressures above 104 mm
Hg, less conclusive in those with lower pressures. This VA
finding has led to the now widely accepted dictum that all
patients with diastolic readings over 104 mm Hg should be
treated. The question of whether those with lower pres-
sures require therapy is still in dispute. Some experts, the
VA's Dr. Freis among them, feel that the answer depends
on other factors in the patient's life and that if the doctor
decides against treatment, he should nevertheless keep
the patient under observation.

Dr. Freis has devised a simple scoring system that
.many doctors find helpful. For patients with diastolic
pressures of 90 mm Hg to 104 mm Hg, he suggests that
one point should be scored for each of the following items
in the history: age below 50, male sex (males are nearly
twice as susceptible as females), black color, diastolic read-
ings that are all 95 mm Hg or higher, target organ dam-
age, and a major hypertensive complication in a parent.
The physician should treat a patient in the 100 mm Hg to
104 mm Hg range, says Dr. Fries, if the score is one or
more; in the 95 mm Hg to 99 mm Hg range if the score is
two or more; and in the 90 mm Hg to 94 mm Hg range if
the score adds up to three or more.

The Hypertension Information and Education Advisory
Committee has simplified the problem, as well as gone
counter to some expert opinion, by deciding to adopt the
160/95 mm Hg standard. "The lower you set it," explains
Dr. John Stokes, the NHLI staffer who serves as executive
secretary for the national program, "the more false-posi-
tives you get. You also may overload the health care sys-
tem."

The national program's recommendations accept the
criterion that a diastolic pressure over 104 mm Hg re-
quires therapy, while treatment of the 95 mm Hg to 104
mm Hg range should be at the doctor's discretion in light
of other factors. They also state that any patient with a
diastolic pressure of 120 mm Hg should be referred imme-
diately and that a patient whose diastolic reading hits 140
mm Hg or more should be hospitalized.

The advisory committee recommends as essential before
starting therapy performing the following tests: ECG,
BUN or creatinine, blood glucose, serum potassium, serum
cholesterol, and urinalysis for protein, glucose, and he-
moglobin. A second line of tests, considered less urgent,
includes a chest x-ray, microscopic urinalysis, and serum
uric acid. The IV pyelogram is regarded as of limited use-
fulness for most patients and reserved for evaluating dif-
ficult cases.

Therapy. In the days before effective antihypertensive
agents were developed, dietary restriction with low salt
intake was the principal therapy. Today most specialists
rely on the battery of drugs now available. However, a
leading cardiologist, Dr. George E. Burch, chief of medi-
cine at Tulane University, re-emphasized the virtues of
dietary management during a lively hypertension sym-
posium at this year's AMA convention, which demon-
strated some of the differences of opinion that still exist
concerning therapy. "I think diet is extremely important,"

he said. "I put all my patients on a largely fruit and vege-
table diet and take them off heavy beef and pork com-
pletely as well as off highly salty food. I don't put them on
a low-salt diet unless they develop malignant hyperten-
sion or renal disease, but I do prescribe a low-cholesterol
diet." Dr. Burch added that patients whose blood pres-
sures fail to respond adequately to diet are given drug
therapy, but diet should be tried first.

Dr. Finnerty strongly disagreed. "The biggest problem
we have is how to keep people under medical care and how
to increase compliance, since most people with mild to
moderate disease feel fine. The worst way to get them to
comply is to restrict their diets. Not that it isn't impor-
tant, especially if there is azotemia or significant disease.

Dr. Cooper: `Simply bringing 10% nzore patients
each year under effective management and full
compliance would constitute significant progress.'

But if you can get the patient to take a pill a day and stay
under care, you're doing a very good job."

Dr. Ray W. Gifford Jr., director of the hypertension and
nephrology department of the Cleveland Clinic, suggested
that diet should "fit the occasion." An obese patient should
reduce, a diabetic should be on restricted carbohydrates,
and a patient with congestive heart failure should be on a
salt-free diet. But for hypertensive patients without prob-
lems of this type, he says, "I make diet the last approach. I
don't say anything about salt in the diet until I find out
they're not responding to a diuretic or a diuretic plus
whatever else I'm using. The average diuretic-say, a
gram of chlorothiazide or its equivalent-will get rid of 8
gm to 10 gm of salt in the diet."

Dr. Freis, who has contributed greatly to the develop-
ment of antihypertensive drug therapy, took a pragmatic
stance: "I don't think it really matters what works as long
as something does. If diet works for one individual, let it
                                     continued

MEDICAL WORLD NEWS/August 24. 1973

75


HYPERTENSION continued

be diet; if pills work for another, let it be pills. The impor-
tant thing is to keep following the patient and following
the blood pressure."

"The aim," added Dr. Gifford, "should be to keep the
blood pressure under control throughout the day, with as
few annoying side effects as possible so the patient won't
stop medication." Here is where some doctors find grounds
for resisting aggressive treatment of mild to moderate
asymptomatic hypertension. They subscribe to the state-
ment made by Dr. W. S. Peart of London in his section on
arterial hypertension in the 13th edition of the Cecil-Loeb
Textbmk of Medicine: "Make sure . . . that the treatment
by drugs is not going to cause more trouble than the un-
derlying condition." In concluding the section, Dr. Peart
observed, "The patient with diarrhea, impotence, tired-
ness, and a normal arterial pressure is not a therapeutic
triumph. To treat hypertensive subjects requires patience,
perseverance, optimism, and a belief that the drugs can be
manipulated in most cases to lower the arterial pressure
while keeping the patient comfortable."

The more than half a hundred antihypertensive agents
fall into three broad classes: diuretics that deplete body
fluids and sodium, compounds that act on the arterioles to
reduce peripheral resistance, and drugs that work by de-

pressing the sympathetic nervous system. Most experts
agree that the first line of attack should be the diuretics,
since many patients can be managed on them alone.

Specialists tend to have their individual favorites: Says
Dr. Gifford: "I still stick by the old thiazide group-it
makes little difference which ones you choose-in spite of
the fact that they produce hypokalemia and hyperuri-
cemia in some patients." Dr. Finnerty finds patient com-
pliance is improved by a one-pill-a-day regimen and starts
with a long-acting diuretic, chlorthalidone. Whatever the
diuretic, the experts advise that one should continue to be
part of every antihypertensive regimen, not only because
of its own effect but because it augments the action of
other agents and prevents them from losing their potency.

If additional fire-power besides diuretics is needed, four
drugs or combinations of them are used most widely: hy-
dralazine, which acts directly on the arterioles; and reser-
pine, methyldopa, and guanethidine, all three of which act
on the sympathetic nervous system. The last named is
usually reserved for patients with moderate to severe hy-
pertension that does not respond to less potent drugs.

The stepped-care regimen proposed by the national pro-
gram's advisory committee includes a thiazide-type diu-
retic as the first step; a choice among reserpine, methyl-
dopa, and hydralazine as the second step; a combination of

reserpine-hydralazine or methyldopa-hydralazine (but not
reserpine-methyldopa) as the third step; and guanethidine
as the fourth. It is recommended that the diuretic be con-
tinued throughout therapy. The regimen's objective is to
reduce diastolic pressure below 90 mm Hg or, if this leads
to too many side effects, below 100 mm Hg.

Not included in these more or less official recommenda-
tions is another compound that is widely used in Europe
for mild to moderate hypertension and is being increas-
ingly used in the U.S.-propranolol. This beta-adrenergic
blocking agent is now on the market for treating ar-
rhythmias but hasn't yet been approved by the FDA for
hypertension. It has nonetheless received the de facto ap-
proval of many specialists, some of whom criticize what
they consider FDA foot-dragging on not only propranolol
but also three other experimental agents.

These possible drugs of the future include bethanidine,
whose action is similar to guanethidine; guancydine; and
minoxidil. The last two act like hydralazine as peripheral
vasodilators, but they are much more potent. The three in-
vestigational agents and propranolol are being evaluated
in controlled trials by the VA as well as by other investi-
gators. Dr. Freis regards minoxidil as especially promis-
ing for treating patients with renal failure and severe
resistant hypertension. "Some patients have responded so
weli", he says, "that we have been able to avoid putting
them on hemodialysis." In addition, he has found that
diazoxide, still awaiting FDA approval after many years
of testing, is effective in treating hypertensive crises.

The NHBPEP is backed up by hundreds of investigators
around the country who are seeking clues to the disease's
etiology, elucidating its biochemical mechanisms, and pav-
ing the way for improved therapy. The cash that flows
through the research arteries is derived largely from the
NHLI and the American Heart Association. NHLI's pro-
posed research budget for hypertension in the 1974 fiscal
year is $26.5 million, an increase of nearly $2 million over
the previous year. Among the projects is the relatively
new SCORE program, an acronym for Specialized Centers
of Research. Five of them specialize in hypertension and
are located at Columbia University under Dr. Laragh, at
Vanderbilt University under Dr. John H. Foster, at the
University of Tennessee under Dr. Ernest E. Muirhead, at
Indiana University under Dr. James T. Higgins, and at
Harvard under Dr. A. Clifford Barger.

Despite the massive organizing effort, the NHBPEP is
inevitably more tortoise than hare. Results are expected
to be gradual and cumulative. "It will take several years
to see a public health effect on morbidity and mortality
rates," says Dr. Cooper.

Among the essentials, he emphasizes, is reaching future
physicians as well as those now practicing "who were
taught many years ago and who may have less access to
newer information than their younger colleagues. The pri-
ority being given to this problem by the AMA and the Na-
tional Medical Association should be very helpful.

"As for the potential 23 million patients," he adds, "we
can't hope that all of them will soon be converted to per-
fect management and compliance. But simply bringing in
10% more each year would make a huge difference." o

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