More Drugs Not Answer to Lower Blood Pressure

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Far too many American physicians today focus on controlling cardiovascular disease (CVD) risk factors with drugs rather than diet and lifestyle changes despite the fact that CVD is caused in large part by poor dietary habits. A very-low-fat, near-vegetarian diet low in salt can prevent and even reverse the CVD process in many cases.

By contrast, CVD risk factor reducing drugs alone are rarely very effective at stopping the progression of CVD although some can be modestly effective in those whose CVD risk factors are quite high. Over the past 30 years medical guidelines have increasingly advocated using more drugs and at higher doses to more aggressively lower CVD risk factors, especially in type 2 diabetes mellitus (DM) patients. However, whether or not more aggressive treatment with most CVD risk reduction drugs are safe and more effective than older treatment goals remains unproven. To evaluate the potential risk and benefits of more intensive CVD risk factor control with pharmacotherapy a series of 4 studies from the ACCORD Study Group were conducted. The New England Medical Journal published the results online in March 2010. The ACCORD Study Group examined the impact of more aggressive pharmaceutical treatments for elevated blood pressure (BP), dyslipidemia, and blood glucose levels in patients with type 2 diabetes mellitus (DM). The results of these 4 studies should make physicians and the pharmaceutical companies question the wisdom of using more drugs and/or higher doses to more tightly control CVD risk factors.

Intensive Drug Treatment of Hypertension Fails

One of the ACCORD trials examined the efficacy of using more BP drugs to more aggressively lower elevated BP in patients with type 2 DM. A total of 4733 people with type 2 DM were randomly assigned to either lowering systolic BP to <120 or to the conventional BP target of <140. In theory pushing BP even lower than the older BP target of <140/90 makes sense because research has clearly shown the risk of CVD events increases dramatically with increasing BP starting at levels below 115/75mmHg. Indeed, the risk of death from CVD roughly doubles for each 20mmHg rise in systolic BP and this is true whether or not one also has diabetes. In this study the average BP for those in the more intensively treated group averaged only 119 compared to 134 in the usual care control group throughout the average 4.7y study period. The greater BP reduction achieved in the intensive BP control group used the same FDA approved drugs used in the control group subjects except that subjects in the more intensive drug treatment group received more of those drugs and/or took the drugs at higher doses than those in the control group. If the higher doses of BP drugs used in the intensive care group completely eliminated the increased CVD risk attributable to higher BP then the greater reductions in BP (Systolic BP reduced 15mmHg on average) seen in this study should have reduced CVD events by about 70%. Unfortunately, aside from a modest reduction in nonfatal strokes seen in the more intensively treated group the lower BP achieved with more drugs did not reduce CVD events or CVD deaths significantly. Worse still total mortality after 4.7y of follow-up was 1.19% in the standard therapy group and 1.28% in the intensive drug treatment group. In addition the study authors found 3.3% of those in the more intensive drug treatment group experienced significantly more serious adverse events attributed to the antihypertensive treatment compared with only 1.3% in the standard treatment group. 2

Bottom Line: The results of the ACCORD studies clearly show prescribing more drugs to more aggressively lower BP and other CVD risk factors in type 2 DM patients is not medically justified. Patients who wish to reverse insulin resistance, hypertension, and dyslipidemia should be told that more aggressive dietary approaches such as a low-sodium, very low-fat, more vegetarian diet and weight loss is not only a far safer but also a far more efficacious treatment strategy than the increasingly knee-jerk response of using more aggressive pharmacotherapy to "improve" blood glucose levels and CVD risk factors. It is a sad commentary on America's drug-oriented approach to healthcare that diseases known to be largely caused by the modern Western diet are largely treated with only marginally effective drugs. Is this not why CVD remains the killer of almost half of all Americans who die each year while the prevalence of type 2 DM continues to rise?

By Dr. James J. Kenney, PhD, RD, FACN

References:

  1. 10.1056/NEJMoa1001286
  2. See Dr. Kenney’s PowerPoint in the cffh library
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