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Am Fam Physician. 2003;67(4):860-862

Approximately 42 percent of patients who are successfully treated for mild to moderate hypertension remain normotensive 12 months after withdrawal of medication. Nelson and colleagues studied patients 65 to 84 years of age who were presenting to general practitioners in Australia to identify factors that predict long-term normotension after withdrawal of antihypertensive medication.

More than 500 patients were recruited from 169 practices. Antihypertensive medication was gradually withdrawn under supervision of a research nurse. Patients who remained normotensive (sitting systolic blood pressure below 160 mm Hg and diastolic blood pressure below 90 mm Hg) two weeks after medication withdrawal were entered into the study. The researchers examined the predictive ability of body mass index, waist-to-hip ratio, diastolic and systolic blood pressure, heavy or higher (binge) alcohol intake, recent exercise (walking or other vigorous activity), number of antihypertensive medications taken, age, and sex. Patients were followed by their general practitioners and by the research team for 12 months.

Follow-up was complete for all but five patients 12 months after withdrawing medications. Overall, 181 (36 percent) patients remained normotensive, 273 (54 percent) patients returned to clinically significant hypertension, and 49 patients (10 percent) had some other outcome. Although the other outcomes included four deaths, they consisted mainly of patients who restarted medications for indications such as cardiac failure (eight) or ankle swelling (18). Approximately one half of patients who returned to hypertension did so in the first 70 days after withdrawal of therapy. In multivariate analysis, the major predictor of normotension at 12 months was low blood pressure during treatment. Other predictors were use of only one antihypertensive drug, younger age (65 to 74 years), and greater waist-to-hip ratio.

The authors conclude that relatively low on-treatment systolic pressure, minimal drug treatment, and younger age are reliable indicators of success in patients remaining normotensive after withdrawal of medication. They point out the substantial potential savings if approximately one third of elderly patients could be managed without antihypertensive medications.

editor's note: Thirty to 40 percent of patients remain normotensive 12 months after withdrawal of antihypertensive medications. For years, we have been crusading to find and treat every hypertensive patient, and the results have been impressive in terms of falling mortality and morbidity from stroke. Have we gone too far? Have we incorrectly labeled nearly one third of our “hypertensive” patients? Besides the costs of medication, office visits, and overt medical expenses, have we subjected these patients unnecessarily to stress and the side effects of medication? The good news from this study is that we can withdraw antihypertensive medications safely in many elderly patients, provided we have good monitoring. I wonder how many other accumulated medications could be withdrawn safely from elderly patients. In particular, the proportion of elderly women taking thyroid replacement medications seems extraordinarily high in my area. Is this a reflection of a true epidemic or a residual from a medical “fashion”? Could I risk withdrawing treatment without making the patients miserable?—A.D.W.

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