In the early 2000s, I included “drugs for mild hypertension” in my book, Money-Driven Medicine: Tests and Treatments That Don’t Work. By 2007, I proposed a Cochrane systematic review of randomized controlled trials (RCTs) to settle the debate. Cochrane is widely considered the “gold standard” of evidence-based medicine; its reviews can shift global clinical practice and multibillion-dollar drug markets.

In 2012, Cochrane published the systematic review of Pharmacotherapy for Mild Hypertension, with me as one of four coauthors. We concluded that there was no evidence that blood pressure-lowering medications for mild hypertension reduced heart attack strokes or any other important outcome. We found that blood pressure-lowering drugs were difficult to tolerate and about 9 percent of patients stop these medications.

Despite these findings, major organizations (the American Heart Association, the American College of Cardiology, and the European Society of Cardiology) continued to recommend aggressive drug treatment for mild hypertension cases. They ignored my 2014 call on KevinMD to retract the influential JNC 8 guidelines.

Notably, 9 of the 17 influential Joint National Committee (JNC 8) panel members had disclosed financial ties to the very pharmaceutical companies (Novartis, AstraZeneca, Daiichi Sankyo, Pfizer, Merck) that dominated the hypertension market.

The 2025 update: A shift in evidence?

In early 2025, I was invited to join an update of our 2012 review. However, I quickly discovered that the inclusion criteria had shifted. My coauthors added a 2004 trial called Prevent IT. This addition was deeply troubling for several reasons:

1. Wrong goal: The primary endpoint of Prevent IT was reducing microalbuminuria in type 2 diabetics, not hypertension-related outcomes.
2. Wrong subjects: None of the patients in Prevent IT actually had mild hypertension. The mean initial blood pressure was 130.6/82.2 mmHg, well below the threshold for the review.
3. The stroke “flaw”: Prevent IT reported one stroke in the treatment group versus 10 in the placebo group. This outlier appeared to be the sole reason for adding the trial, as it skewed the entire Cochrane update to suggest that drugs “may reduce the risk of stroke.”

I raised these concerns with my coauthors and eventually filed a formal complaint with the Cochrane editor-in-chief. My complaint was never vetted; it was simply ignored. I insisted on remaining a coauthor, hoping to recruit my coauthors for an RCT of “Artificial Intelligence Assisted Analysis of Mild Hypertension Treatment, Complications, and Non-Drug Alternatives.”

The missing data

I proposed an alternative review using AI-assisted analysis to look at nondrug alternatives. In my research, I found that the most significant RCT on this topic, the Treatment of Mild Hypertension Study (TOMHS), had been excluded from both the 2012 and 2025 reviews.

In the TOMHS study, all participants received lifestyle advice (weight loss, salt reduction, exercise). In the placebo group alone, systolic blood pressure dropped by 9.1 mmHg. The drug-treatment group did show a slightly lower rate of cardiovascular events (5.1 percent versus 7.3 percent), but the p-value was 0.21, meaning the result was not statistically significant. When I asked to include this data, I was told the lead author would not release the full dataset to our team.

When the “cure” becomes the cause

Using AI modeling, I estimated that blood pressure drugs used for mild hypertension contribute to 12,000 to 50,000 additional hip, femur, and pelvis fractures annually in the U.S. alone. In the early 1980s when these original RCTs were done, seniors over 65 years old comprised 11.3 percent (≈25.5 million) of the U.S. population; in the early 2020s, seniors comprised 16.8 percent of the population (≈55.8 million).

These drugs make patients nearly five times more likely to discontinue treatment due to dizziness, weakness, and fatigue. For an elderly patient, a moment of dizziness leads to a fall; a fall leads to a fracture; and for 20 percent to 30 percent of seniors, a hip fracture leads to death within a year.

I tried to publish these findings in Cureus, a peer-reviewed journal that has published several of my papers; it was rejected because I had no coauthor. Two preprint journals rejected it without explanation.

Recently, my own partner, who was taking the blood pressure-lowering medication amlodipine, suffered a fall and femur fracture. While I cannot definitively prove the medication was the cause, the clinical pattern is hauntingly familiar. In September 2025, Cochrane published the mild hypertension update over my objections. By suggesting these drugs “may reduce stroke” while downplaying the fatal risks of falls, we are failing the very patients we are sworn to protect.

David K. Cundiff is a physician, author, and health care reform advocate whose work centers on transforming the U.S. health care system and addressing broader societal challenges, including climate change. He is the author of Grand Bargains: Fixing Health Care and the Economy, which proposes structural reforms to dramatically reduce health care costs while improving outcomes. His essay “Much Better Healthcare for Way Less Cost” explores accountable care cooperatives and community-based reform. Additional works include Money Driven Medicine – Tests and Treatments That Don’t Work and Whistleblower Doctor: The Politics and Economics of Pain and Dying.

From 1981 to 1998, Dr. Cundiff practiced, taught, and conducted clinical research in internal medicine and pain control at the Los Angeles County + USC Medical Center, where he directed the Cancer and AIDS Pain Service for nine years, and previously held an academic affiliation with Harbor-UCLA Medical Center. After exposing how systemic inefficiencies increased hospital utilization and revenue, he became a whistleblower, an experience documented in Whistleblower Doctor.

Outside his professional work, Dr. Cundiff values time with friends and family, including six grandchildren, and maintains his health through Hatha yoga, meditation, swimming, Zumba, biking, and a diet emphasizing minimally processed organic food.