Is Hypertension Important?

In 1990, there was little doubt that moderate and severe hypertension were important risk factors for vascular disease. New data on adults from the Framingham study [2] suggest that even a borderline elevation of systolic pressure with normal diastolic pressure (isolated systolic hypertension) may be a risk factor. In 1995, hypertension is still an important condition with substantial implications for personal and public health.

Is Hypertension Detectable and Does Detection Lead to Treatment?

Littenberg and colleagues [1] concluded that sphygmomanometry "is useful in detecting asymptomatic hypertensive patients." In other words, they considered only patients without manifestations of the sequelae of hypertension, such as stroke. Since then, reports on investigations of both screening (in persons who are not patients) and case-finding (among patients presenting for other reasons) have been published. Several reports show that screening persons who are not patients, such as persons at a shopping center or in the workplace, rarely leads to the treatment of previously untreated persons with hypertension [3-9]. The links between identification and control are often too weak to justify extensive community screening programs. Nonetheless, many patients with hypertension in the United States have become aware of their diagnosis and are receiving treatment [10]. I conclude that hypertension is detectable and that detection can sometimes lead to treatment. However, a good detection program must include a structured process for follow-up and treatment.

Is Treatment Effective?

In 1990, the efficacy of treatment of moderate and severe hypertension in middle-aged adults was unquestioned [1]. No new evidence has challenged the value of treating patients less than 70 years of age who have diastolic pressures consistently greater than 105 mm Hg. Several new trials have concentrated on older persons [11-13]: Each found that treatment significantly reduced the occurrence of strokes; one showed that treatment had a favorable effect on total mortality. Meta-analysis has shown that treatment of patients over 60 years of age produces a significant benefit [14].

What is the Effect on Health of Screening for Hypertension?

Previously published estimates of the efficacy of screening [1] have been qualitatively unchanged over the last several years. Screening an asymptomatic adult for hypertension yields a modest average benefit of less than 3 weeks additional expected life span; the benefit depends on the age and sex of the adult. As it would be in all screening programs, this average benefit is distributed unevenly throughout the screened population. Most persons will receive little or no benefit, but an important minority will reap tremendous advantages in morbidity and mortality averted.

Benefits and Harms

I know of no injuries or fatalities directly caused by sphygmomanometry. However, screening can lead to a cascade of indirect harms, including side effects of medication; labeling as sick an otherwise functional person; and initiation of a diagnostic evaluation that can be directly catastrophic (if it involves invasive tests) and indirectly dangerous (if it leads to inappropriate therapy). For many persons, the balance of harms and benefits will favor periodic screening. However, some adults will reasonably prefer to avoid the potential harms of screening. Individual decisions should be made on the basis of the values and preferences of individual persons.

Health Outcomes Versus Economic Outcomes

In 1990, Littenberg and colleagues [1] found the cost per quality-adjusted year of life gained by screening to vary according to age, sex, and various assumptions in the model. Since 1990, the cost of treating hypertension has increased substantially. The cost of the drug regimen used to treat hypertension is an important determinant of the cost-effectiveness of screening for high blood pressure. For instance, if medications, laboratory tests, and physician care for hypertension costs $1500 per year, the cost-effectiveness of screening 40-year-old women will be a substantial $119 000 per quality-adjusted year of life. If annual care costs only $500, the cost per quality-adjusted year of life decreases to $39 000 (Table 1). Because newer pharmaceuticals are much more costly than older agents, and because most of the trials that show treatment to be beneficial used older, less expensive medications, I fully endorse recommendations to use diuretics and ß-blockers as first-line therapy for hypertension [10].

Limitations of this Analysis

I may have missed some information that would substantially alter these recommendations. However, given the high visibility of hypertension in the medical literature and the concordance of these recommendations with others [10, 15], a major omission appears unlikely. The analysis presented here depends critically on the previously published analysis by Littenberg and colleagues [1]. Any errors in that work will be propagated here.

Recommendation

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The results of this review suggest that previous recommendations for screening [1] are still appropriate. Specifically, all adults should periodically be offered sphygmomanometry in a case-finding setting. This can be done during most visits to a physician, nurse, or clinic and as part of the periodic health examination. Treatment of hypertension should be done using the least expensive regimen that is consistent with efficacy and safety.