As part of a series on heart disease, Gina Kolata of the New York Times is calling attention to Blood Pressure, The Mystery Number.
And what a mystery it is! Reading Kolata’s piece, one gets a sense that hypertension researchers are chasing after the optimal blood pressure the way Pythagoreans of old sought numeric answers for the riddles of the universe.
What about a patient like Glenn Lorenzen, 67, whose systolic pressure was a frightening 220 in October? On a chilly day in December…he had received the good news that drugs and weight loss had lowered his reading to 124. Should he be happy? Should he aim to be below 120? Or should he ease up on the medications a bit and let his pressure drift toward 140 or even 150?
Unfortunately, with Lorenzen’s happiness hanging in the balance, doctors must make decisions “in a fog of uncertainty.” What’s worse, even biostatisticians are helpless: “We don’t know which is right,” says David Reboussin, an expert in numeric science who hopes the answer will be revealed in a “rigorous study” called Sprint. (The Pythagoreans, too, had a penchant for austerity and exercise).
“Guideline makers have a conundrum” and are “all over the map,” Kolata says, prompting some to look for the right numbers elsewhere: Can the blood cholesterol number enlighten us as to the optimal pressure value? Will it reveal the sweet spot on the “J curve,” the point of intersection between maximum benefit and minimum risk?
Only time will tell, of course, but we may wish to remember that the current generation of physicians and scientists is not the first one to be puzzled by the mystery of the blood pressure. Some fifty years ago, George Pickering expressed his bafflement about the “force” inside our arteries as follows:
The ‘disease’ essential hypertension…is thus a type of disease not hitherto recognized in medicine in which the defect is one of degree not of kind, quantitative not qualitative.
But Pickering had no interest in determining the ideal quantity of pressure. Such a pursuit, he thought, was motivated by “the fallacy of the dividing line.” Instead, Sir George and Baron Platt were occupied with a decidedly more Aristotelian question: It was the nature of hypertension that was worth debating, not any cut-off number to artifactually distinguish health from disease.
Pickering and Platt have gone to their final rest, while the neo-Pythagoreans remain relentless in their quantitative pursuits. But as Herb Fred and I have tersely argued, answers to the riddle of hypertension come not from interrogating spreadsheets or pondering statistics, but from examining patients, lest we go on treating them “by the numbers, for the numbers.”