Labelling of hypertensives: a review of the data

‘People say it is dangerous’

Introduction: Mild hypertension is a common asymptomatic condition present in people at low risk of future cardiovascular events. These people represent approximately two-thirds of those diagnosed with hypertension. The best available evidence does not support pharmacological treatment for mild hypertension to reduce cardiovascular mortality. Additionally, overdetection of hypertension also occurs, and this practice is supported by public awareness campaigns, screening, easy access to testing, and poor clinical practice, enhancing the overdiagnosis potential. Moreover, sparse qualitative patient-oriented evidence that diagnosing hypertension has harmful consequences is observed. Therefore, evidence regarding the potential for unintended psychosocial effects of diagnosing mild hypertension is required. Objective: The aim of this study was to investigate if diagnosing low-risk people with mild hypertension has unintended psychosocial consequences. Methods: Eleven semi-structured single interviews and four focus groups were conducted in São Paulo, Brazil, among people diagnosed with mild hypertension without comorbidities. Informants were selected among the general population from a list of patients, a primary healthcare clinic, or a social network. The informants had a broad range of characteristics, including sex, age, education level, race/skin colour, and time from diagnosis. Data were subjected to qualitative thematic content analysis by three of the authors independently, followed by discussions, to generate categories and themes. Results: The informants confirmed that the hypertension diagnosis was a label for psychosomatic reactions to stress, medicalised illness experiences, and set a biographical milestone. We observed unintended consequences of the diagnosis in a broad range of psychosocial dimensions, for example, fear of death, disabilities, or ageing; pressure and control from significant others; and guilt, shame, and anxiety regarding work and leisure. Although informants had a broad range of characteristics, they shared similar stories, understandings, and labelling effects of the diagnosis. Conclusion: The diagnosis of hypertension is a significant event and affects daily life. Most of the impact is regarded as negative psychosocial consequences or harm; however, sometimes the impact might be ambiguous. Patients’ explanatory models are key elements in understanding and changing the psychosocial consequences of the diagnosis, and healthcare providers must be aware of explanatory models and psychosocial consequences when evaluating blood pressure elevations.

Factors affecting health-related quality of life among hypertensive patients using the EQ-5D tool

OBJECTIVES

Hypertension (HTN) is a major risk factor for cardiovascular disease, it is an epidemic health problem with 1 billion people affected worldwide. Limited studies have examined the impact of HTN on physical, psychological and social functioning of HTN patients. Furthermore, little is known about factors that impair these domains among these patients. Thus, the aim of the present study is to assess health-related quality of life (HRQoL) and to explore predictors of poor HRQoL in patients with HTN in Jordan.

METHODS

Hypertensive patients visiting cardiology and internal medicine departments were recruited from three major hospitals in Jordan. Patients' Socio-demographics and medical data were collected via direct patient encounters and medical records. The validated Arabic version of EQ-5D tool was used to assess HRQoL. Simple linear regression was performed to explore the factors associated with poor HRQoL.

RESULTS

The mean score of the EQ-5D index of the 300 participants was 0.732 (SD = 0.29, range from -0.594 to 1.0). While extreme problems were only reported by 10% of the participants, most of them reported "some problems" through the five dimensions with the highest percentage (43.3%) for mobility dimension. Gender, monthly income, number of medical conditions, number of medications, number of HTN medications, duration of HTN and the presence of any atherosclerotic cardiovascular diseases were significantly associated with the EQ-5D index value (P-value <.05).

CONCLUSIONS

The current study highlights factors that negatively impact HRQoL in patients with HTN. Such findings should provide useful information for future pharmaceutical care intervention programmes aimed at improving HRQoL and other health outcomes in patients with HTN.

Development of an item pool for a questionnaire on the psychosocial consequences of hypertension labelling

Background

Hypertension is the most prevalent risk factor for cardiovascular disease globally. Roughly one-third of the adult population has hypertension. However, most people diagnosed with hypertension do not benefit from blood pressure control with pharmacologic interventions: they are overdiagnosed and overtreated and might experience negative psychosocial consequences of being labelled. These consequences are relevant outcomes that need to be assessed and validly measured to identify all benefits and harms related to interventions designed to prevent cardiovascular disease.

Objectives

To develop a pool of items with high content validity for a draft version of a condition-specific questionnaire to measure the psychosocial consequences of being labelled with mild hypertension.

Methods

We selected relevant items from existing Consequences of Screening (COS) questionnaires. These items belonged to two groups: COS core items and potential condition-specific items. All items were originally in Danish and were translated into Brazilian Portuguese using the dual-panel method. Individual and group interviews were conducted with people with mild hypertension and low risk for cardiovascular disease, and were designed to test the translated items for face and content validity and were also used to generate new relevant items. Structured individual interviews were conducted to categorise all the items into domains.

Results

The Brazilian Portuguese dual-panel translation of both groups of items was found to be relevant for adults diagnosed with hypertension. We generated 52 new items to achieve high content validity. The result was a set of 132 items divided into 22 domains in 2 parts. Part I was directed at the general population, whereas part II was directed only at people diagnosed with hypertension and it consisted of 38 items in 8 domains. Twelve items remained as single items. High content validity was achieved with the pool of 132 items divided into 22 domains in 2 parts.

Discussion

High content validity was achieved for a condition-specific questionnaire measuring the psychosocial consequences of being labelled with mild hypertension. This instrument encompassed 132 items divided into 22 domains in 2 parts. Thereby, a draft of the Consequneces of Hypertension questionnaire (COH) was developed. The psychometric properties of this questionnaire will be discussed in a diferent paper.

New onset diabetes during antihypertensive therapy

New onset diabetes (NOD) is common among hypertensive patients, whether they are being treated for hypertension or not, and is associated with subsequently increased cardiovascular disease (CVD). Thiazide-like diuretics and beta-blockers are more likely to provoke hyperglycemia when compared with drugs that block the renin-angiotensin system, and calcium channel blockers. However, in contrast to the NOD arising during treatment with other antihypertensive drugs, the NOD that occurs during diuretic treatment, has not been shown to increase CVD, either in clinical trials, or during longer observational studies. In fact, blood pressure reduction achieved by diuretic treatment may avert the expected increase of CVD in NOD. Conventional blood pressure reduction (along with lipid lowering) is the proven approach to preventing CVD in diabetes, in whatever circumstances the diabetes occurs. Apprehensions relating to the potential onset of NOD should not influence the choice of the initial antihypertensive treatment choice, nor should it invariably lead to discontinuation of diuretics (although such a step may reverse hyperglycemia). NOD can also sometimes be eliminated by correcting hypokalemia with a potassium-sparing diuretic, and/or potassium supplementation, or by adding a potassium-conserving antihypertensive drug such as an ACEI, ARB, or an anti-aldosterone agent. If all these stratagems fail (or are unsuitable), and the diuretic is essential to blood pressure control, then hypoglycemic therapy is indicated. NOD does adversely affect quality of life, and is not to be accepted lightly. However, diuretic-induced hyperglycemia can be managed, and should be tolerated if a diuretic is essential for blood pressure control. In summary, the potential for occurrence of NOD certainly needs consideration, but it is not an insurmountable challenge, and must not compromise aggressive blood pressure control, which remains the primary tool for antihypertensive care.

Hypertension and health-related quality of life: an epidemiological study in patients attending hospital clinics in China

OBJECTIVE

To examine the relationship between hypertension and health-related quality of life in patients attending hospital clinics in China.

DESIGN AND METHODS

A cross-sectional survey. Patients over the age of 35 years attending outpatient clinics in 18 hospitals of eight major cities of northern and southern China were interviewed between June and July, 1999. Trained fieldworkers completed questionnaires regarding demographics, hypertension knowledge and awareness, treatment history and quality of life issues. Qualified physicians performed blood pressure assessments.

RESULTS

A total of 9703 volunteers were enrolled; 4510 (46.5%) had hypertension. The results showed that hypertensive subjects scored lower in the multiple linear regression analyses in most questions on the quality of life questionnaire than those without hypertension after controlling for age, sex, sociodemographic factors, and co-morbidity. There was a strikingly high prevalence of physical complaints or symptoms. Among the variables considered, age, sex, hypertension, body mass index, educational level, smoking, history of cholesterol, family history of cardiovascular diseases and history of diabetes were statistically significantly correlated with health-related quality of life. Subjects aware of having high blood pressure had a lower health-related quality of life score than subjects with high blood pressure but unaware of the diagnosis. Among treated subjects, those with controlled hypertension had higher health-related quality of life scores than those with poorly controlled hypertension.

CONCLUSIONS

Hypertensive individuals represent a vulnerable population that merits special attention from healthcare providers and systems. This is especially important given that low health-related quality of life can be a risk factor for subsequent cardiovascular events or complications.

The effect of treatment on health-related quality of life in patients with hypertension and renal artery stenosis

The quality of life in patients with hypertension is considered to be impaired mainly by side effects of antihypertensive drug therapy. Since balloon angioplasty for renal artery stenosis has a medication-sparing effect, it may lead to an improvement in quality of life. The objective of the study is to compare the effect of antihypertensive drug therapy and balloon angioplasty on quality of life in patients with hypertension and renal artery stenosis. We compared the quality of life in 56 patients randomised to balloon angioplasty to that in 50 patients randomised to antihypertensive drug therapy after 3 and 12 months of follow-up. Quality of life was measured using a questionnaire on physical symptoms associated with hypertension and antihypertensive drugs, and two generic health questionnaires (MOS Survey and EuroQol instrument). After follow-up, the patients who underwent angioplasty used less antihypertensive drugs than the patients who were treated with antihypertensive drugs only (mean+/-s.d., 1.9+/-0.9 vs 2.5+/-1.0 drugs after 3 months, P=0.002). They reported similar physical complaints, however, and a similar quality of life. The results after 12 months of follow-up were the same. In conclusion, for patients with hypertension and renal artery stenosis, the decrease in antihypertensive medication after intervention is too small to lead to a detectable improvement in quality of life.

Use of decision aids to support informed choices about screening

Decisions about screening can be more complex than those about treatment. Well designed decision aids could help patients understand the risks as well as the benefits

Factors involved in deciding to start preventive treatment: qualitative study of clinicians' and lay people's attitudes

OBJECTIVES

To explore the views of clinicians and lay people about the minimum benefit needed to justify drug treatment to prevent heart attacks, and to explore the rationale behind treatment decisions.

DESIGN

Qualitative study using semi-structured interviews.

PARTICIPANTS

4 general practitioners, 4 practice nurses, and 18 lay people.

SETTING

8 general practices and 6 community settings across Liverpool.

RESULTS

Participants varied widely in the minimum acceptable benefits chosen. Most people found the concepts difficult initially, and few appreciated that increased length of treatment should increase absolute benefits. Lay people usually wanted to make decisions for themselves, and clinicians supported this. Participants wanted to consider adverse effects and costs of treatment. Dislike of drug taking was common, and many people preferred lifestyle change to an imperfect treatment. Quality of life and personal views were more important than an individual's age.

CONCLUSIONS

Evidence based guidelines make assumptions about people's preferences, and, by using 10 year estimates of risk, inflate the apparent benefits of treatment. It is unlikely that guidelines could incorporate the wide range of people's preferences, and true dialogue is necessary between clinicians and patients before starting long term preventive treatment.

Chronic renal ischemia: implications for cardiovascular disease risk

Chronic renal ischemia caused by atherosclerotic renal artery stenosis (RAS) is gaining recognition as a potentially important risk factor for cardiovascular (CV) morbidity and mortality. The etiology of increased risk of CV events is multifaceted and includes direct physiologic changes that increase risk as well as intermediate clinical effects that are associated with worse outcome. Physiologic changes associated with increased CV risk in patients with RAS include increased production of fibrogenic and vasoactive peptides such as renin, angiotensin, endothelin, and catecholamines, as well as endothelial cell dysfunction. Clinical intermediate conditions associated with higher incidences of CV events seen in patients with renal ischemia include hypertension, systemic atherosclerosis, chronic renal failure, and left ventricular hypertrophy and dysfunction. More thorough understanding of the myriad physiologic changes seen in patients with RAS will likely improve patient selection for renal artery revascularization. Clinical trials should examine a full range of CV and renal outcomes, not just blood pressure, to adequately assess the merits of revascularization.

Coronary and cardiovascular risk estimation in uncomplicated mild hypertension. A comparison of risk assessment methods

OBJECTIVE

To compare the accuracy of five risk assessment methods in identifying patients with uncomplicated mild hypertension at high coronary heart disease (CHD) and cardiovascular disease (CVD) risk.DESIGN Comparison of risk estimates using each risk assessment method with CHD risk 15% and CVD risk 20% over 10 years calculated using the Framingham risk functions.

SETTING

British population.

SUBJECTS

People aged 35-64 years with uncomplicated mild systolic hypertension (systolic blood pressure (SBP) 140-159 mmHg, = 202) from the 1995 Scottish Health Survey.

MAIN OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive values.

RESULTS

Compared with CHD risk 15% over 10 years, the Sheffield table and Joint British Societies (JBS) Chart had good sensitivity and specificity ( 90%). The New Zealand (NZ) Chart had sensitivity 83% and specificity 89%. Compared with CVD risk 20% over 10 years the Sheffield table had sensitivity 81%, the JBS Chart had sensitivity 63%, and the NZ Chart had sensitivity 75%. All had good specificity ( 90%). For CHD risk and CVD risk the World Health Organization/International Society of Hypertension (WHO-ISH) and United States Joint National Committee VI (JNC-VI) methods had high sensitivity at the cost of very poor specificity ( 50%).

CONCLUSION

In patients with uncomplicated mild hypertension, the Sheffield table and JBS Chart both identified CHD risk 15% over 10 years with acceptable accuracy, while the NZ Chart was less accurate. Compared with CVD risk 20% over 10 years, these three risk assessment methods were all less accurate, but the Sheffield table retained the highest sensitivity ( 0.05 versus JBS Chart, = NS versus NZ Chart). The WHO-ISH and JNC-VI methods had unacceptably low specificities compared with both measures of risk and failed to differentiate between those at high and low risk.

Hypertension and health-related quality of life. an epidemiological study in Sweden

The aim of this study was to describe the relationship between hypertension and health-related quality of life (HRQL) in a Swedish general population using the 36-item short form questionnaire (SF-36). The study is based on a postal questionnaire that was sent to a random sample of 8000 inhabitants aged 20-84 years (response rate 68%) in Uppsala County, Sweden, in 1995. The results showed that those with hypertension scored lower in the linear regression analyses in most of the eight domains of the SF-36 than those without hypertension after controlling for age, sex, sociodemographic factors, and comorbidity. Diabetes and angina pectoris were related to lower scores in most of the domains of the SF-36. Previous myocardial infarction was associated with lower general health and vitality. Those with a previous stroke had lower scores in physical functioning, general health, vitality, and social functioning. The findings suggest that hypertensives represent a vulnerable population that merits special attention from health care providers and systems. This is especially important given that low HRQL can be a risk factor for subsequent cardiovascular events or complications.

Effects of a health examination programme on quality of life and subjective well-being

The effects on quality of life and psychological well-being of a health examination programme in a branch of Swedish industry were studied by means of questionnaires in 124 white-collar workers. They were asked to answer two questionnaires, one before and the other one month after the examination (the Nottingham Health Profile (NHP) and the Psychological General Well-being Schedule (PGWB)). Both are well-known and well-documented standard questionnaires used for estimating quality of life and degree of subjective well-being. The answers were compared with those of a control group comprising other white-collar workers in the same industry, of the same sex and age but who did not participate in the health examination and who were asked to complete the same questionnaires twice. The group that had participated in the health examination did not differ generally from the control group with respect to intra-individual differences as studied in the questionnaires on the two occasions. This indicates that no deterioration of quality of life or of psychological well-being was experienced by the participants in the health examination.

Cost-effectiveness of hypertension treatment

The benefits of antihypertensive treatment are influenced by both the absolute initial cardiovascular risk, and the relative reduction. Because age is a major determinant of the absolute cardiovascular risk, and because the strategies for hypertension diagnosis and treatment are not very much influenced by age, hypertension management appears to be more cost-effective after the age of 45, in both men and women. Below this age, the absolute gain in life-years seems to be smaller, and sensitivity analysis demonstrate an important influence on the results of assumptions about the effects of treatment on quality of life and the discounting rate.

Follow-up study of participants in an extensive health examination programme at a Swedish industry

Two years after an extensive health examination at a Swedish industry, a follow-up study was carried out in 110 employees (94% of those initially examined). The control included a history of the subject's health, a physical examination, an electrocardiogram, urine and faeces examinations and 16 chemical analyses of whole blood or serum. Except for repeat examinations of those who had had initial values outside reference values, most of the chemical analyses meant nothing, leading to unnecessary expense and possible risk of either worried or complacent participants. The history and physical and laboratory examinations, aimed at finding factors which can be improved by changing the life style seem to be most beneficial. It is concluded that extensive health examinations, including a large number of laboratory examinations which are carried out at many industries as a health control, should be critically evaluated at these industries.

Why is preventive medicine exempted from ethical constraints?

It is a paradox that medical experimentation on individuals, whether patients or healthy volunteers, is now controlled by strict ethical guidelines, while no such protection exists for whole populations which are subjected to medical interventions in the name of preventive medicine or health promotion. As many such interventions are either of dubious benefit or of uncertain harm-benefit balance, such as mass screening for cancers or for risk factors associated with coronary heart disease, there is no justification for maintaining the ethical vacuum in which preventive medicine finds itself at present.