American Society of Hypertension, Inc
Leadership Message

WHAT DOES IT MEAN TO BE THE “VOICE” OF HYPERTENSION?

Those of you who have read the now‐released strategic plan of the American Society of Hypertension (ASH) know that we are striking out in a new direction. We will become the voice of hypertension in America. We will use our influence to improve the care of hypertensive patients worldwide. As president‐elect, I am honored to have the opportunity to lead our society in its new mission to make a meaningful impact on this most important of cardiovascular risk factors.

Our challenge is huge. There are at least 60 million Americans with elevated blood pressure (BP) and another 30 or 40 million whose “normal” BP puts them at increased risk of the already‐known consequences of having elevated BP (strokes, coronary heart disease, heart failure, peripheral arterial disease, chronic kidney disease) and conditions such as dementia, which are likely to be a consequence of hypertension. ¹ The worldwide burden is even greater, with estimates that there will be 1.26 billion hypertensives in the world by 2025. ²

We have an enormous amount of data to support our mission. We have been in the randomized clinical trials business since the 1960s, when the first Veterans Affairs (VA) Cooperative Study, led by Edward D. Freis, MD, clearly showed a skeptical scientific community that drug therapy for patients with diastolic hypertension reduced cardiovascular events. ³ , ⁴ This year, 2007, marks the 40th anniversary of the publication of the first portion of that trial, which shows the results in patients with a diastolic BP of 115 to 129 mm Hg after an extensive qualification period. ² It took only 141 participants and 18 months to show a benefit (21 events in the placebo group vs 1 event in the active treatment group). Since then, beginning with the Hypertension Detection and Follow‐Up Program (HDFP) ⁵ in the 1970s through the Antihypertensive and Lipid‐Lowering Trial to Prevent Heart Attack (ALLHAT) ⁶ in this decade, numerous trials sponsored by government (the National Institutes of Health and the Medical Research Council, among others) and industry have unambiguously proven the value of treating both systolic and diastolic hypertension in all age groups and in those from diverse ethnic backgrounds. ⁷ These trials showed that reducing BP lowered stroke rates by approximately 35% to 40%, heart attacks by 20% to 25%, and heart failure by 50%. ⁸ But it wasn't until we studied older patients and patients with isolated systolic hypertension that we could say with certainty that treating hypertension would prevent coronary heart disease. ⁷ I have always wondered why we in the hypertension community apologized for preventing “only” strokes and not necessarily heart attacks. I have yet to meet anyone who would have preferred to have a stroke rather than a heart attack, knowing they were going to survive.

ALLHAT also confirmed that thiazide‐like diuretics were unsurpassed as initial therapy for older and high‐risk hypertensives. ⁶ This year also marks the 50th anniversary of the introduction of thiazides, a drug class whose low cost and wide availability make it feasible for the medical community to undertake a national or international campaign to protect everyone from the consequences of hypertension.

Several secular and scientific trends frustrate our ability to protect the population from the consequences of hypertension. These issues are already a major problem in the United States and elsewhere. We are getting older, fatter, and more sedentary. ⁸ , ⁹ Though we have reliable data on the benefits of lifestyle modification, our behavioral colleagues have been unable to figure out how to sell this idea to the public and providers. In addition, the data from Lewington and colleagues ¹⁰ on the risk for patients with what the Seventh Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) ¹ called prehypertension is compelling. These data have pointed out the risk of having an elevated BP from 115/75 mm Hg from age 40 onward, regardless of other risk factors. Anyone still unconvinced about the primacy of BP as a risk factor needs only to ponder the results of the Investigation of Lipid Level Management Using Coronary Ultrasound to Assess Reduction of Atherosclerosis by Cholesteryl Ester Transfer Protein Inhibition and High‐Density Lipoprotein Elevation (ILLUSTRATE). ¹¹ In that trial, high‐density lipoprotein cholesterol was dramatically increased, low‐density lipoprotein cholesterol was significantly reduced, and atherosclerosis was unchanged in the face of a rise in BP. In addition, the Hypertension Trialist Group ¹² has shown that it is the lowering of BP, not what we use to do it, that matters most. Other extensive analyses of trial data demonstrate that lowering systolic BP by what would be an insignificant amount in an individual (3–5 mm Hg) has enormous value in a population (25%–30% reduction in cardiovascular events). ¹³ , ¹⁴

In my view, we in ASH must dedicate ourselves to lead the way in getting hypertension back in the spotlight. We must do the following:

• •Stop arguing about which drug to use first and focus on getting BP reduced. Until proven otherwise, it is not beyond the BP, it is the BP.
• •Focus on the unmet needs in evaluation and treatment of hypertension.
• •Figure out how to better stratify hypertensives and prehypertensives so that treatment is directed at those who are likely to benefit and spare those who are truly at low risk from the consequences of treatment they don't need. Perhaps the recent work from the Framingham Heart Study will help us be more successful. Wang and colleagues ¹⁵ , ¹⁶ have suggested that traditional risk factors predict major events and incident hypertension extremely well and that newer biomarkers add little. B‐type natriuretic factor and urinary albumin‐to‐creatinine ratio were the most useful measures in predicting cardiovascular events and death, while C‐reactive protein, plasminogen activator inhibitor‐1, and the urinary albumin‐to‐creatinine ratio were most helpful in predicting incident hypertension. Knowing BP, cholesterol, smoking status, body mass index, renal function, and diabetes status provided most of what we needed to know to prognosticate.
• •Persuade individuals and policy makers to embrace the behavioral changes we know would be helpful. Is this a political, business, or marketing issue? It took the advocates of the problems of global warming many years to make believers of almost everyone, so we must not get too impatient. Let's take a leaf from our British colleagues and work hard to limit excess sodium in foods and get R ratings for films that show actors smoking.
• •Help to develop new approaches to treating patients with resistant hypertension, either with agents that lower systolic BP more effectively or by better combining what we already have. The resistance against using fixed‐dose combinations, which was so prevalent in the 1970s and until recently, seems to finally be over. Lest we forget, the regimen used in the first VA study was a fixed‐dose combination of hydralazine, reserpine, and hydrochlorothiazide, the largest‐selling antihypertensive in the 1960s. ²
• •Discuss the development of a polypill. In 2007, we do not have the clinical trial evidence, with the possible exception of the Trial of Preventing Hypertension (TROPHY), ¹⁷ that the risk‐benefit equation of treating prehypertensive patients with drugs will be favorable. Do we need to wait until we do, or should we proceed without the level 1A evidence that some think we need? We surely cannot recommend exposing low‐risk persons to the potentially serious side effects of drugs. But such an approach for the prehypertensive patient is sensible, as long as the elements in such a tablet are eminently safe. ¹⁸ , ¹⁹ If behavioral therapy and lifestyle modifications were effective and their benefit sustained, we wouldn't need to worry about which drugs to put in a polypill.
• •Develop better treatments for hypertensive emergencies. Hypertensive emergencies are unusual; however, there is still a need for new and better parenteral ways to safely reduce BP.
• •Write hypertension guidelines. For now, we will be issuing a series of short position papers on subjects of interest to the hypertension specialist. But we may find it necessary for us to update JNC 7 or at least actively assist in National Heart Lung and Blood Institute‐sponsored guideline development.
• •Do more if we are to be the voice of hypertension. Should ASH work with the Centers for Medicare and Medicaid Services and other providers of care to recognize hypertension specialists and augment our reimbursement accordingly? We have long provided an excellent forum for the discussion of scientific issues in hypertension, but we need to do more if we are to be the voice of hypertension—we must serve our members, as well as our community and society.

We have the brains, we have the commitment, and we have the will. Now we must be effective.