Pills or Even Tea More Palatable Than Exercise for the Treatment of Hypertension, US Adults Say

Exercise is low on the list of interventions US adults are willing to endure for the treatment of high blood pressure and gaining extra time alive, a new survey shows.

Taking a pill or drinking a daily cup of tea were the two preferred treatments, with individuals less likely to want to exercise or take injections to gain an extra month, year, or 5 years of life, report investigators.

Erica Spatz, MD (Yale University School of Medicine, New Haven, CT), who led the study, told TCTMD that in conversations with patients about medication and lifestyle modifications needed to reduce cardiovascular risk, some people can be reluctant to adopt any of her recommendations.

“As physicians, we need to realize that many of our interventions come at a cost for patients, not just with side effects or out-of-pocket costs, but in the simple inconvenience,” said Spatz. “Many people have an aversion to taking a pill or exercising, and there is an associated burden—what we’re calling disutility—that is associated with our recommendations to reduce cardiovascular risk.”

In a survey of 1,384 US adults asked to imagine a scenario in which they had hypertension (if they didn’t have it already), 79% said they would be willing to take a pill for an extra month of life, 90% to gain an extra year of life, and 96% to gain an extra 5 years of life. Similarly, near identical numbers of participants said they’d be willing to drink a cup of tea—an intervention chosen to represent placebo given that it was likely least burdensome to patients—for those gains.

In contrast, however, just 63%, 84%, and 93% were willing to exercise to gain an extra month, year, and 5 years of life, respectively.

“That really surprised me,” said Spatz. “I honestly thought that exercise would have much bigger uptake. I thought that taking a pill would be perceived as being much more inconvenient than people thought.”

As physicians, we need to realize that many of our interventions come at a cost for patients, not just with side effects or out-of-pocket costs, but in the simple inconvenience. Erica Spatz

Overall, the results show that “most people would start a therapy for hypertension with little or nominal gain, though there is still substantial heterogeneity among treatments,” she added.

Neil Stone, MD (Northwestern University Feinberg School of Medicine, Chicago, IL), who was not involved in the study, acknowledged the challenges patients encounter when tasked with making significant changes to their lifestyle, whether that is starting an exercise program or adhering to a heart-healthy diet. To help in the process, he has previously devised the “ABCD” framework for counseling patients on making lifestyle changes.

The framework includes assessing (A) the patient’s perception of their current lifestyle and motivation to change, as well as the barriers (B) that might stand in their way to making those changes. It involves getting patients to commit (C) to measurable goals and helping them demonstrate (D) progress.

“It doesn’t take long,” said Stone, the chair of the 2013 US guidelines for the treatment of high cholesterol. “[It takes] a few minutes to find out if change is possible and how you can assist in that change, understanding that at the end of the day, if the patient doesn’t want to change, they’re not going to. If the patient decides they want to change, but if they don’t see it as a priority and can’t make a commitment, the recidivism rate has been shown by many studies to be very large.”    

Not Big Fans of Injections Either

In the study, which was presented April 7, 2018, at the American Heart Association’s Quality of Care and Outcomes Research Scientific Sessions in Arlington, VA, the researchers also found that many weren’t too keen to take an injection to lower their blood pressure and extend their life. For example, only 51% would take a monthly injection to gain 1 month of life, 74% to gain 1 year of life, and 88% to gain an extra 5 years. Individuals were more willing to take injections every 6 months, however. In total, 68%, 85%, and 93% said they’d be willing to get an injection semiannually if it translated into an extra month, year, or 5 years of life.

Spatz said they asked if patients would be willing to take a monthly injection given the introduction of PCSK9 inhibitors, which are delivered via a subcutaneous injection once per month. While no such injections exist for the treatment of hypertension, they wanted to assess the disutility inherent to taking the monthly shot.

“It might be exciting to the field, to offer something that’s not a pill and is not given on a daily basis, but is it more acceptable to patients to get a monthly injection and forget about it?” said Spatz. “We were surprised that it didn’t have good uptake.” She added, however, this needs further exploration, particularly since they didn’t explain how or where the drug would be administered, factors which might have influenced individuals’ answers.

Overall, more than 20% of those surveyed considered the burden of any treatment to exceed the calculated life-expectancy gain. Spatz noted that a previous study conducted by researchers in the United Kingdom addressed medication disutility with statins. In that study, investigators asked healthy individuals how much statin-derived benefit would be required for them to consider taking the LDL-lowering medication. Overall, approximately one in four patients required a benefit that surpassed the average treatment effects of statin therapy. Even in high-risk patients, disutility exceeded the gains statins would be expected to provide.

In general, adherence to cardiovascular medications, regardless of whether they’re used for primary or secondary prevention, hovers around 65%, said Spatz. Many people discontinue what are intended to be lifelong medications after a year or just beyond it. While their study assessed the disutility of taking an antihypertensive medication, the results are likely similar in other cardiovascular conditions, including acute coronary syndrome.

“There’s a sizeable proportion of people who are really averse to taking a pill, even when there is a big benefit to be gained,” said Spatz. “If adherence rates are any indication of the disutility that people find with therapy, you could potentially say the same thing for antiplatelet therapy. When you look at adherence to antiplatelet therapy, even after myocardial infarction, the adherence rates are only around 70% or so. And that’s a high-risk condition.” 

Empathizing With Patient Challenges

Spatz said that clinicians need to acknowledge the aversion patients have to medication or exercise, because it shows they understand and empathize with the work needed to adopt and maintain a new lifestyle or to take a daily pill.

“Additionally, I think we need to talk more about what are realistic benefits from these therapies and whether they align with people’s goals,” she said. “People might have different expectations of benefit, and we might come to a joint conclusion that this preventative therapy is not consistent with what you would expect to gain from it and might not be the best thing for you.”

Stone noted that when he consults some patients about starting an exercise program or dietary changes, occasionally a patient can break down in tears.

“For example, they might be single mothers and at the end of a brutal day, they might have kids that just want to go to McDonald’s,” he said. “They don’t have time to go home to prepare food or exercise.” In such instances, he tries to find compromises, such as asking individuals to walk a few extra blocks or take the stairs when they can and to make healthier choices even at fast food places.

“It’s very important to encourage people who might feel like life is ganging up on them,” said Stone.