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Rapid Responses: Rapid Responses published:
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There is a non-linear relationship between mortality and blood pressure
- Jorgen Vesti-Nielsen (23 May 2003)
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White coat mercury gauge related hypertension offset by American variant aneroidosis
- Phillip J. Colquitt (24 May 2003)
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PRE HYPERTENSION.
- Graeme M. Mackenzie (24 May 2003)
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Let's get physical!
- Malvinder S. Parmar (26 May 2003)
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US response to blood pressure is not normal
- Michael R Leacock (27 May 2003)
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JNC VII-The Collateral Damages
- Dr.Aravind P Pillai (29 May 2003)
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A rapidly accelerating demise
- Dr.Herbert Nehrlich (30 May 2003)
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Looking for eternal youth
- Angel L Martinez (2 June 2003)
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PRE HYPERTENSION
- Graeme M Mackenzie (4 June 2003)
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Jorgen Vesti-Nielsen, Consultant Physician Blekingesjukhuset, 37480 Karlshamn, Sweden
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Statistical modelling = torturing of data gave a linear relationship between blood pressure and risk of death in the Framingham data, and this has since been the official credo. Shockingly - the Framingham data themselves do in no way support the statistical model, the relationship is still a non-linear one.[1,2] The threshold for increase of risk still follows approximately the old rule of thumb: 100 plus age. The point has been well illustrated in the HOT study. There is no increase in cardiovascular mortality, AMI or stroke until after 160-170 mmHg. [3] But how has it come so far that medical 'science' has more trust in statistical models than in real world data. And why is it that the medical profession put up with advice from experts' models completely disconnected from real world data. Poor Americans. And for the rest of us, God save us when our turn comes. 1 Port S, Demer L, Jennrich R, et al. Systolic blood pressure and mortality. Lancet 2000;355:175-180 2 Port S, Garfinkel A, Boyle N. There is a non-linear relationship between mortality and blood pressure. European Heart Journal 2000;21:1635- 1638 3 Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Jorgen Vesti Nielsen Consultant physician Competing interests: None declared |
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Phillip J. Colquitt, Technical Advisor Self-employed
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It happens when I go to the GP. Things conspire to make me "pre- hypertensive" at 120/80, as in Tanne[1] - that leaky mercury(Hg) column on his desk[2] with a typically unhygienic communal cuff, the tinkers collection of dusty old sphygmomanometer parts up there on top of his cupboard, and the knowledge that Hg from hospital sphygs' have recently caused nosocomial pneumonia and classic Hg poisoning symptoms needing treatment[3]. I wonder about my GP's vapour exposure from visible and invisible spilled Hg droplets, dermal translocation, and vacuum aerosol. His work environment meets none of the criteria for using mercury in the workplace. He writes me a script and his handwriting looks less than flowing. Is he pre-clinical for Hg poisoning, or is it just the usual doctors handwriting? My transient hypertension is prevented from becoming chronic, with the linked reference given in Tanne[1]. The link[4], opens to a US government department headlined page on high blood pressure, and features colour pictures of the often maligned, yet occupationally safe and now promoted, aneroid sphyg' exclusively. [1] Tanne JH. US guidelines say blood pressure of 120/80 mm Hg is not "normal". BMJ 2003;326:1104 (24 May). [2] Tenace L. Do You Have a Baumanometer[R]? Environmentally Preferable Purchasing News for Health Care Organizations Vol.2 No.1 January 2000. Available at: http://www.state.ma.us/ota/pubs/eppjan00.htm Accessed on May 24 2003. [3] Baddi L, Ray D. An unusual nosocomial pneumonia. Chest. 2002 Sep;122(3):1077-9 [4] The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) http://www.nhlbi.nih.gov/guidelines/hypertension/ Accessed on May 24 2003. Competing interests: Mercury exposure |
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Graeme M. Mackenzie, GP Whitehaven Cumbria UK CA28 7RG
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The medical world has finally lost it. If this approach to health and disease is adopted then we will all go mad. Already I think we need a backlash against the endless collection of risk factors and their managment. This just makes such a backlash inevitable. Should I set up pre-disease clinics in my practice. Of course my patient group is everyone in my practice. I will see them how often? CAN WE PLEASE JUST START ACCEPTING THAT WE ARE ALL MORTAL AND GET ON WITH ENJOYING LIFE!!!! AND COULD THESE RESEARCHERS PLEASE GET A LIFE! Competing interests: None declared |
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Malvinder S. Parmar, Medical Director, Internal Medicine Timmins & District Hospital, Timmins, Ontario, Canada
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Aging is the single most important predictor of the development of future hypertension. Data from Framingham Heart Study (1) suggests that individuals who are normotensive at 55 years of age have a 90% lifetime risk for developing hypertension. So, in addition to lifestyle modification (Diet, exercise etc), if one could slow the aging process then may decrease the onset of future hypertension. Lifestyle modification essentially is the only way, at present, that that could improve your chronological age (than real age) and may prevent future hypertension. Again, lifestyle modification remains the only preventive measure in contemporary materialistic society. Governments, corporations and the society should modify the working conditions and reduce demands on individuals time constraints and promote exercise. Reference: 1. Vasan RS, Beiser A, Seshadri S, et al: Residual lifetime risk for developing hypertension in middle-aged women and men: The Framingham Heart Study. JAMA 2002; 287:1003-10. Competing interests: None declared |
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Michael R Leacock, None London
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The guidelines quote "individuals who are normotensive at 55 years of age have a 90% lifetime risk for developing hypertension". Surely if 90% of patients are 'at risk' that is normal under most statistical rules?. I would suggest rather than the patient's blood pressure be deemed to be abnormal or 'pre -disease', we should deem the guidelines in the US as being at the very least pre-hyperbole and probably close to disease status! Competing interests: None declared |
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Dr.Aravind P Pillai, MPH Scholar Achutha Menon Centre For Health Science Studies,SCTIMST,Trivandrum,Kerala,India.695011
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Joint national committee report(JNC) VII- The collateral Damages It is obvious that the new guidelines will label millions of people as prehypertensive and hypertensive. Nobody defies hypertension as a risk factor for Carcio vascular disesase(CVD). But marketing tactics, playing with numbers, confusing doctors and lay public with statistical jargons warrant for rethinking. Unit changes in cut off values can rope in millions of people into the treatment category. The JNC states why they have come up with this new report. To a great extend its based on meta analysis. But what are the conflicting interests in those individual studies and how they arrived at these values remains gray. How far these guidelines can be applied universally considering the ethnic and regional variations is another question. The last JNC report was reprinted (JNC VI) in attractive formats and distributed with logos of pharmaceuticals companies in many of the medical schools in India. The sponsors conducted academic session for fresh graduates and post graduate students a grand gala ceremony followed by the product briefing (anti hypertensive as advised in JNC). The most striking feature of all these dissemination programmes were that they completely side lined options like losing weight, exercise, drinking less alcohol, reduced sodium intake, and changing diet to the "DASH" diet (high in fruits and vegetables, potassium, and calcium) other than drug treatment. Further experiences showed that the programme was a huge success in confusing risk factors with diseases and making a significant impact on the prescription practices of, young doctors. The statement made by Dr Thomas Kottke, professor of medicine at the Mayo Clinic, Rochester, Minnesota, who wrote an accompanying editorial in JAMA "Yapping at people doesn't help,"1 will have far reaching consequences if it is selectively highlighted by the pharmaceutical, emphasizing the need for drug treatment and neglecting alternative strategies. This is more significant for patients and doctors in developing countries were availability of unbiased medical information is scarce. And what is available is the promotional literature with selectively screened information, and lay press, which will come up with stories in the most imaginative way booming the sales of anti hypertensives. 1 Janice Hopkins Tanne BMJ 2003; 326: 1104-a Competing interests: None declared |
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Dr.Herbert Nehrlich, Private Practice Bribie Island Australia 4507
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As far as I am concerned: 100 plus your age is perfectly acceptable (again).The same people who would put the masses (including children) on statins are busy inventing conditions that need to be 'managed'.My hair is getting quite gray and I was wondering.... A contributor recently wrote about 'the demise of a once honorable profession'. Competing interests: None declared |
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Angel L Martinez, internal medicine specialist Hospital de Leon. Altos de Nava. 24008 Leon (Spain)
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The new approach of the NJC 7 classifying levels of BAP between 115/75 and 180/80 as "at risk" has two consequences: first, the near breakdown of our Hypertension units under thousands of poor frightened people, and second the unfortunate classification as "non healthy" of people who are never going to have a major cardiovascular event. Anyway, we have to deal again with the population heterogeneity, and thus the difficult task of applying the Framingham data to other countries. For instance, in Spain the prevalence of CAD is near 100/100.000, within in USA it oscillates between 800 and 700/100.000. How could we recommend the same interventions for both? I am afraid that we assist a new edition of the old dream of inmortality protagonized by a misleaded medical class. Please, donīt go on this way. We would prefer to enjoy our life a little bit, if possible. Competing interests: None declared |
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Graeme M Mackenzie, GP Whitehaven Cumbria CA28 7RG
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Further to my submission above I really should behave and not mention the increased use of more expensive drugs for not only an asymptomatic condition but an adisease condition. I must phone my stockbroker immediately Competing interests: None declared |
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