The More Things Change, the More They Remain the Same

This issue of The Journal of Clinical Hypertension (JCH) marks my last as editor‐in‐chief. JCH was conceived in 1999 to serve a purpose somewhat different from that of the available hypertension journals. ¹ These were of high quality but were only being read by about 2500 to 4000 nephrologists and experts in the field of hypertension. Up‐to‐date specific information about the management of hypertension and cardiovascular risk factors was not being made available to the large number of physicians who treated hypertension, which was and still is the most common reason why adults go to their doctors. Mr Le Jacq, a medical publisher, was determined to change this and get the hypertension management message out to 40,000 to 50,000 family practitioners, internists, and cardiologists. I was initially skeptical but later enthusiastically accepted the responsibility of becoming editor‐in‐chief of the journal.

It has been a remarkable and exciting journey. The journal has succeeded largely because of the hard work of the editorial board, which includes experts from the United States and other countries, who have been most generous with their time in writing commentaries and in helping in the review process. In an interview in 2005, Dr Henry Black noted that “a lot of arms were twisted in these initial days to get things started” but that people were grateful that they had been convinced to contribute to the journal. ² In addition, numerous reviewers have been conscientious in reviewing and critiquing articles that have appeared in the journal. A warm word of thanks to them and to the many people such as Jan Basile, Michael Bloch, Henry Black, Tom Pickering, Ray Townsend, Debbie Cohen, Dom Sica, Joel Handler, and Don Vidt for their ongoing efforts in writing reviews and columns.

Starting next month, Dr Michael Weber will become editor‐in‐chief. Mike has had many years of experience in the world of hypertension and will undoubtedly move to extend the influence of JCH, the official clinical journal of the American Society of Hypertension since 2005. As the nature of the message changes, content may be expanded to include more information about risk factor management and heart disease prevention.

A great deal of progress has been made in the treatment of hypertension since 1999, but some of the comments in the early issues of JCH suggest that many issues are the same today as they were in 1999. A few quotes from editorials from 1999 to 2002 may be of interest. For example, an editorial in September 1999 noted that only 50% of all patients with hypertension (defined as blood pressure [BP] >140/90 mm Hg) were under treatment but that only about 30% were controlled at goal levels. Numerous reasons for this were advanced: some patients did not consider elevated BP a serious problem; treatment could be expensive and time‐consuming; patients discontinued medications when their BPs were reduced to normal because they were “cured.” There were patients who were reluctant to take medication at all because of possible side effects. ³ This all sounds familiar 10 years later. A mixed message had been sent to physicians that lowering BP might not reduce coronary heart disease events and might even increase them—clearly a message not based on the available evidence in 1999. The editorial board pleaded for a clear message that treatment was successful not only in reducing cerebrovascular events but also cardiovascular events. A clear message was sent that reducing the diastolic BP below 80 to 85 mm Hg in older people did not increase coronary events. A clear message was sent that lifestyle interventions alone, although effective in lowering BP in some patients, should not represent definitive therapy in the majority of patients. A clear message was sent that available medications could be given without serious side effects. And finally, a clear message was sent (even in 1999) that reducing BP to levels lower than the goal of <140/90 mm Hg in diabetic patients was a reasonable approach. The editorial board concluded that if we could move away from the recurring debate that “my drug is better than your drug” and clarify some of the concerns of patients and physicians, we would increase the number of patients under control—a message that is still germane 10 years later.

The number of hypertensive patients who are controlled has increased dramatically during the past 10 years. Based on data from the Behavioral Risk Factor Surveillance Survey ⁴ and a recent Harris poll, ⁵ more than 80% of hypertensive patients are now being treated with specific medications and about 50% are controlled at goal levels of <140/90 mm Hg. Levels of control in diabetic patients, however, are lower. It is not surprising that today the goal of 130/80 mm Hg or below in diabetic patients or in patients with renal or coronary heart disease has not been achieved in large numbers of patients. These recommendations were established only a few years ago, and it will take more time to achieve this goal in more people.

It is of interest to quote an editorial in the January 2000 JCH that discusses a dilemma that is still being debated. Is it the BP alone or specific effects of specific medications that reduce events? A large meta‐analysis had reported that most of the benefit achieved in reducing morbidity/mortality resulted from BP lowering and not specific medications. This is still the belief of many experts, but some exceptions were agreed upon. ¹ In diabetic patients angiotensin‐converting enzyme (ACE) inhibitors and angiotensin receptor blockers given with a diuretic were recognized as the drugs of choice in patients with diabetes or diabetic nephropathy. ² The clinical trials of the late 1990s had indicated that calcium channel blockers and diuretics were more effective in the elderly than β‐blockers or renin‐angiotensin system blockers, that ACE inhibitors and diuretics were probably more effective in reducing the occurrence of heart failure, and that the use of a calcium channel blocker–based treatment program might be more effective in reducing strokes than some other therapies. Basically, the message was, the lower the BP the better the outcome. The 2000 editorial ended by stating that “new trial results reinforce recommendations that several or multiple drugs are necessary to decrease BP to goal levels.” ⁶ Again, a recurrent theme over the past 10 years. ⁷ , ⁸

The use of combination therapy was actually emphasized in many of the early JCH editorials in 2000–2001. It was repeatedly noted that monotherapy, regardless of which medication was used, ie, a diuretic, β‐blocker, calcium channel blocker, ACE inhibitor, or angiotensin receptor blocker, would not reduce BP to goal levels in a large number of patients. An editorial in September 2000, which reviewed all of the recent trials, noted that “the discussion of which drug to be used first may be moot. Most patients require more than one medication to reduce BP to goal levels” and “that starting a patient on combination therapy could be the answer to better BP control and better adherence to therapy.” ⁹ Subsequently, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) in 2003 recommended the initial use of 2‐drug therapy in patients with stage II hypertension or possibly in patients with stage I disease with target organ involvement. ¹⁰ Thus, practitioners who received JCH (and read the articles) had been advised of newer approaches to hypertension management in advance of the JNC report. Providing practitioners with up‐to‐date information has been and is the mission of JCH.

In November 2000, an editorial on the treatment of the elderly emphasized that lowering BP reduced strokes and cardiovascular events and that treatment of individuals 80 years and older had also significantly reduced strokes and heart failure. ¹¹ Recent data from the Hypertension in the Very Elderly (HYVET) study have confirmed that treatment of these patients is beneficial ¹²; yet, it is in this group of patients that BP control rates are poor. Surveys continue to suggest that there are many physicians who will not treat older patients, especially those older than 70 years, unless systolic BPs are >150 or even >160 mm Hg. Ongoing efforts of the JCH to improve outcome in elderly patients have included several expert panel discussions that have emphasized the benefits of treatment. ¹³

An editorial in May 2001 highlighted another ongoing debate about the management of resistant or difficult‐to‐treat hypertension. In 1988, Dr Irvine Page, one of the pioneers of modern therapy, commented that “there are hypertensive patients who are resistant to treatment but they are few. The resistance I’m afraid lies more with a physician who failed to monitor carefully the course of the patient’s BP.” ¹⁴ Clinical or physician inertia has repeatedly been discussed in JCH. ¹⁵

All of the above highlight just a few of the ongoing issues in hypertension management that JCH has sought to convey to practicing physicians.

Random thoughts about other issues that relate to the medical care system, scientific publications, and JCH

Several editorial board members have suggested that JCH become more involved in issues other than hypertension management. JCH editorials have expressed concern about some of the problems in medical education and scientific publications. In October 2001, an editorial commented on the status of medical research and the publication of scientific papers. ¹⁶ Twenty or 30 years ago, a new treatment or drug was studied by physicians who were experts in the field. Researchers could modify a study design in the course of their research if some observations suggested a different use of the drug or procedure. Today, data collection is strictly protocol‐driven. Trials are carefully designed and conducted. Specific objectives are outlined. Hundreds of physicians who are not necessarily experts in a field may be engaged in a study. Each may enroll only a few patients. Protocol violations or serendipity is not allowed. Clinical research has been redefined. In some instances this is necessary. Anecdotal reports are less frequent, but, in many cases, innovation is stifled.

JCH editorials have frequently discussed another problem. Editors of scientific journals are concerned about papers that are clearly written by science writers and signed off by prominent experts. ¹⁷ Some of these papers have been reviewed by the experts but many appear to have been approved without careful review. Many have a beginning, a middle, and an end to prove a promotional point. There is something wrong with a physician putting his/her name on a paper with little involvement and oftentimes receiving an honorarium for doing it. Transparency has been advocated and science writers are now being given credit for writing, but we are missing the point. If research is done, it should be reported and written up by the researcher. He/she can have help with the protocol description and with statistical data but should be responsible for the discussion and conclusions. In addition, negative trial data should be published more often and statistical data carefully reviewed. These decisions should not be left exclusively in the hands of a study sponsor.

In May 2002, another JCH editorial discussed the question of the future of postgraduate medical education, especially as it relates to hypertension. ¹⁸ Pharmaceutical companies have made enormous strides in developing effective and well‐tolerated medications and clearly many of us would not be alive today had it not been for these advances. But some change is necessary to clarify the role of industry in postgraduate education. Articles in JCH have advocated more vigilance with regard to the influence of industry on medical education. More and more symposia and hospital grand rounds are not only being sponsored by industry but are being controlled by industry or symposia management companies. There is a great difference between attending continuing medical education nonsponsored grand rounds at a hospital and attending a symposium sponsored by a specific company. In the latter case, one expects to hear about a new drug or procedure. There is little objection to this type of program, but far too many product messages are presented at lectures that are intended to convey an up‐to‐date nonbiased opinion.

The medical profession has dramatically changed in the past 30 years. Medicine, once viewed as a profession, is now viewed by many as a business or a trade. Some of the changes represent advances, but many do not. Filling telephone prescriptions or seeing patients in the hospital are now viewed by some physicians as outdated. Hospitals and physicians advertise their wares as if they were department stores. People are paying doctors for the privilege of becoming their patients. Hospitalists have made the treatment of hospital patients more and more impersonal. Drugs off patent that have been used successfully for years are no longer used and often abandoned. A review of lectures or medical journal articles rarely turns up the mention of these older drugs, yet many of them are still highly effective. Have these problems just become part of the system or are they modifiable? ¹⁹

As JCH moves forward under the leadership of Dr Weber, some of these issues will continue to surface. I am certain that the journal will continue to maintain the quality of its publications and a high degree of scientific credibility while providing the practicing physician with clinical updates that are useful to him/her in their practices.