Abstract
It is appropriate that Raymond Gifford, Jr., MD, is considered an icon of hypertension. Dr. Gifford has been actively involved in research and treatment efforts in the field of hypertension for more than 45 years. He has been a strong voice in correcting the myths and misconceptions that prevailed in the 1940s and early 1950s about this disease. Dr. Gifford and other physicians at the Mayo Clinic were among the first to recognize that lowering blood pressure could reverse some of the complications of severe hypertension. They demonstrated that reducing blood pressure would help clear retinal hemorrhages, relieve symptoms of congestive heart failure, and at least temporarily reverse the syndrome of malignant hypertension. Later in his career, at the Cleveland Clinic where he was chairman of the Department of Hypertension and Nephrology for many years, Dr. Gifford worked with Irv Page, Harriet Dustan, Emanuel Bravo, Ed Frohlich, Bob Tarazi, and others on the causes of secondary hypertension. Dr. Gifford was involved in evaluating almost all of the antihypertensive drugs from the 1950s, including the peripheral and ganglion blocking agents, and did some of the early studies on diuretics. I have been fortunate to observe and interact with Dr. Gifford through many of these projects, at meetings and seminars, at the National Heart, Lung, and Blood Institute, and at quiet dinners. He possesses the unique ability to clarify an issue in one or two sentences that oftentimes will have been debated for hours. When Dr. Gifford speaks, people listen. I am always pleased when Dr. Gifford agrees with me; I know I must be right. In the following interview, Dr. Gifford minimizes his contributions, which extend far beyond his involvement in the National High Blood Pressure Education Program and his work at the Cleveland Clinic. Dr. Gifford is retired from practice and the Clinic, but remains a strong voice in the world of hypertension as a frequent speaker at national and international meetings where he always presents an unbiased, scientifically accurate point of view.
DR. MOSER: Ray, what do you consider your major contributions in research and hypertension treatment?
DR. GIFFORD: At the Mayo Clinic my major contribution was the investigation and development of sodium nitroprusside as an antihypertensive agent for hypertensive emergencies. This was at a time when many people just accepted malignant hypertension as a death sentence. At the Cleveland Clinic it was simplification of the diagnostic evaluation of the hypertensive patient. I remember early on that we used to require intravenous pyelograms as a routine procedure, looking for correctable causes of hypertension. Tests for pheochromocytoma, which was so rare that it was hardly worth looking for, were done routinely. I evaluated that and showed it wasn't necessary to do intravenous pyelograms and tests for pheochromocytoma routinely in the pretreatment evaluation of hypertensive patients.
DR. MOSER: You published an important paper detailing the actual incidence of treatable forms of hypertension. As I remember, the total number of cases, except for renal parenchymal disease, was under 1%. I agree that your findings were the major contribution.
What about your contributions to the National High Blood Pressure Education Program?
DR. GIFFORD: I was chairman of the Fifth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) and participated in all but JNC II. I represented the American Medical Association on the High Blood Pressure Coordinating Committee of the National Heart, Lung, and Blood Institute and got a great deal of satisfaction out of that because the reports helped spread the gospel about the treatment of hypertension. And although some physicians thought that the JNC algorithms represented “cookbook” medicine, time has shown that when a protocol or algorithm is followed, results of treatment are much improved.
DR. MOSER: What about the recent tendency toward making the workup more complicated? There are many physicians today who believe, for example, that ambulatory blood pressure monitoring should be part of the routine workup. There are also many who believe every patient should have an echocardiogram before treatment. Does this go against your intuition and your belief that the diagnostic evaluation for hypertension should be simple?
DR. GIFFORD: It certainly does. I don't believe ambulatory blood pressure monitoring is necessary except in a very few patients. Echocardiography is rarely necessary in the evaluation of hypertensive patients. Patients should and can be treated whether or not they have evidence of left ventricular hypertrophy.
DR. MOSER: If you had to put on your forward‐looking hat and tell us what will be the next major challenge physicians will face in the management of hypertension, what would you say—increasing patient compliance, improving physician compliance, setting new guidelines, or looking for new treatments? Do we have effective treatments now or should we be looking for something different and going in a different direction? Are we on the right path in looking for a cure, and are we closer to identifying truly specific causes?
DR. GIFFORD: I think we have very effective treatments now. They are just not being used effectively. Many hypertensive patients are not having their blood pressure controlled to ideal levels. I think that's a major problem for the future—not a lack of medications. If you use the currently available medications appropriately, they will reduce blood pressure to a desirable level.
I don't think physicians realize what the desirable level is. It's below 140/90 mm Hg. This has been demonstrated over and over again. When we get the majority of hypertensive patients controlled to below 140/90 mm Hg, we will have achieved a great advance.
DR. MOSER: Is that your target? I have heard you say that we should be aiming for as close to 120/80 mm Hg as possible—if it's achievable.
DR. GIFFORD: That's still my feeling because we know from long‐term epidemiologic evidence that patients who have blood pressures below 120/80 mm Hg do better, live longer, and have fewer vascular complications of hypertension.
DR. MOSER: You mentioned getting more patients to goal, but you didn't mention anything about patient adherence to therapy. Is your belief that most of the problem relates to the fact that physicians aren't treating to goal? Perhaps we've been blaming patients too much over the years for their lack of adherence or compliance.
DR. GIFFORD: Yes, I think so. I believe it's more of a physician problem than a patient problem. I don't think patients are being told what their blood pressure should be. I think that when they are told, we will see a dramatic decrease in blood pressure. They will put pressure on their doctors to treat them more aggressively.
DR. MOSER: There has been a lot of work and a lot of time, energy, and money spent on gene research in hypertension. We know that this disease is multifactorial with many genes involved. Do you envision a time when gene research will lead to gene alteration and a different type of more definitive therapy, or is that too far in the future?
DR. GIFFORD: As far as I am concerned, that's too far in the future to be of any practical current value. One last point: We have made progress in identifying possible causes of hypertension and, as you said, they are multifactorial, but we still are a long way from finding a cure. In the meantime, we can prevent complications even if we don't completely understand why so many people have this disease.