Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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To get control patients need control
- Matthew P Doogue (12 March 2004)
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Big Brother knows best
- Dr. Herbert H. Nehrlich (14 March 2004)
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Hypertension - is it really a disease?
- Paul A Sackin (15 March 2004)
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Missing numbers
- Peter Davies (15 March 2004)
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GUIDELINES GALORE, NO GUIDANCE!
- BM Hegde (17 March 2004)
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Matthew P Doogue, Diabetes Registrar Christchurch Hospital
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Our efforts to control blood pressure parallel our efforts to control blood sugar, doomed to failure until we give patients control. The closer to the patient the decision making, the better blood sugar control. The best blood sugar control is achieved by patients who both have the tools and know how to use them. Our roll is to provide the tools and train the user. This works best if patients can record a targetable endpoint and follow a clear plan to achieve the target. The next best is someone close to the patient, third is a professional with frequent contact with the patient such as a district nurse or general practitioner. Occasional contact with specialist clinics is the least effective intervention. Blood pressure can now be measured by simple relatively cheap home devices, analagous to blood glucose monitors. Good training by nurse educators and simple algorithms will achive better outcomes than sophisticated tests and one off specialist opinions. Competing interests: None declared |
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Dr. Herbert H. Nehrlich, Private Practice Bribie Island,Queensland Australia
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Here we go again! Blood pressure measurement to "identify" those in need of preventive measures. I would like to see some credible evidence that shows a definite positive effect on cardiovascular disease. Cholesterol, blood pressure, blood sugar, triglycerides, perhaps uric acid etc. - my friend Eduard thinks we would be better off not knowing. His cholesterol is 260 and his BP 164/94 and he is a happy-go -lucky fellow. Lifestylism, coercive medicine, altruistic medicine, preventive medicine - all are supported by the powers of the state. Which makes me think that they may not be so desirable after all. Pro-active Medicine? That only means one thing: Making healthy people into potential patients.Treating hypertension does NOT reduce the incidence of cardiac complications, says I. The book "THe Disease Inventers" by Jörg Blech comes to mind. Proactive Medicine or Prevention was, after all, inherited from the Nazis and the Totalitarian regimes of the East. I begin to worry when I see the bureaucrats setting health care policy. BP, TC, .....Frankly, my dear it is none of your business and makes no difference in the long run! Competing interests: None declared |
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Paul A Sackin, General Practitioner Alconbury, Huntingdon, Cambridgeshire, UK. PE28 4EQ
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We are told that the prevalence of hypertension is 42% in people aged 35-64. This must mean that in older patients, the condition is present in well over 50% of the population. With such a huge prevalence it is not surprising that control of this 'disease' in the UK is so poor. Perhaps GPs would have been wise to calculate the time and effort (never mind the ethics) involved in controlling the blood pressure of millions of elderly patients before accepting this aspect of the new GMS contract. More importantly, has the disease model for diagnosis and treatment of hypertension been accepted by the population at large? Do people really want polypharmacy, with its attendant risks, in order to make it marginally less likely they will die of cardiovascular disease and so marginally more likely they will die of something else? Or could it be that the dependence of the multibillion pound drug industry on anti- hypertensive agents is stifling the debate? Competing interests: From April 1st, as a UK GP, part of my income will be related to the control of my patients' hypertension. |
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Peter Davies, GP Mixenden Stones Surgery, Mixenden, Halifax, HX2 8RQ
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Sir, The new BHS Guidelines (1, 2) exemplify both the best, and the worst, features of our current medical thought processes. They exemplify the best in that they collate evidence from many trials and transform it into a clear and useful form. They define the problem clearly and positively guide us as doctors, and patients, on future treatment of the defined problem. Yet as they achieve this they miss some important wider issues. Maybe this is a deliberate omission, or maybe the authors are not fully aware of these problems. From a secondary care perspective seeing patients on admissions wards with strokes due to hypertension it would appear to make sense to generalise from this and say that everyone with hypertension would benefit from blood pressure reduction. Yet when viewed from a primary care or public health viewpoint such a view is far from proven. (3) The hypertension guidelines give no information on numbers needed to treat to achieve a reduction in cardiovascular events. Yet the numbers who may need treatment are vast at 42% of those aged 35-64 (about 12 million people) (1) They also give no information on the figures that matter to an individual patient, namely their personal probability of benefit (4) from treatment and the number needed to harm, either by pharmacological side effects or the psychological side effects from having a disease label. Until these numbers are explicit, I as a primary care physician cannot know whether in any individual case I am doing more harm or good to an individual patient by diagnosing hypertension. If I do not know this I cannot really give my patient accurate information about treatment and so I cannot really obtain informed consent to, and concordance with, any treatment plan. And this lack is a major omission before we decide whether to set out to implement these guidelines and whether they can achieve successful reduction of individual levels of cardiovascular risk. Refs 1. Laurent,S, (2004) Guidelines from the British Hypertension Society BMJ 328:593-4 2. William,B, Poulter,N.R., Brown,M.J., Davis,M., McInnes,G.T.,Sever,P.S. et al (2004) British Hypertension Society guidelines for hypertension management 2004. (BHS-IV): summary BMJ 328:634-40 3. Tate,P (2002) Hypertension: a tutorial for our time Education for Primary Care 13:541-3 4. Misselbrook,D and Armstrong, D. (2002) Thinking about risk: Can doctors and patients talk the same language? Family Practice 19:1-2 Competing interests: None declared |
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BM Hegde, Retired Vice Chancellor Mangalore-575004, India
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Dear Sir, “Typical patients are far from typical” Voltaire. One more guideline! There are already six or more guidelines. When computed together they cover less than half of the hypertensive population in their inclusion criteria. The remaining half does not fit into any guideline. The practising doctor will have to use his/her "intelligent guess" under those circumstances since there are no typical patients. While we recommend combined therapy, based on arm chair reasoning, there are hardly any controlled studies of drug combinations that resemble the long laundry list prescriptions of real world these days.(1) Even under ideal conditions, combinations of drugs had more side effects that forced patients to withdraw from studies. Despite that intention-to-treat analysis was used to compute the final results.(2) I am not aware of any study that looked at the very long term effects of anti- hypertensive drugs given to apparently healthy population in the fond hope of averting strokes, heart attacks etc. One small study did show that, after the first five to ten years of drug treatment, even the well controlled hypertensives had much higher death rates compared to their normotensive cousins in society. (3) We still have no data to show how low is low enough blood pressure, as the J-curve still haunts us in this area. The J-curve was not burnt out even by the modern studies.(4) We do not know what happens to the sleep blood pressures in those patients having very low clinic readings. If the sleeping pressures really go down further, in the middle aged and the elderly, the diastolic coronary filling could go down drastically. Let us remind ourselves that the statistical methods that we have used have served us well in acute infectious diseases set up. The game changes when we come to chronic illnesses. ` Time evolution in a dynamic system is not linear and there are “butterfly effects” happening in this area like in predicting the weather accurately.(5) My experience (experience fallacious, judgement difficult, I know) tells me that we have been predicting the unpredictable using linear statistical methods. Even the controlled studies are flawed to a degree that there are no two individuals alike, although we randomize the groups. The MRC study did show that to save one patient from stroke we will have to unnecessarily treat nearly 850 people with mild-to-moderate hypertension for five long years with drugs that are not free from side effects when pro-actively looked for.(6) The important reasons for poor pressure control are also outside the realm of drugs. Multiple drugs make compliance go down exponentially! Life style modifications are not stressed while loading patients with drugs. The so-called primary hypertension is due to the negative feelings in the mind most of the time.(7) If that is not given due importance and set right the results will be the same despite another dozen guidelines. Studies have shown the good effects of meditation and yoga in this area. There are many other imponderables in this game. One can not put the whole gamut of hypertension care into a water-tight compartment of "Disease Vs Drugs" scenario. Diet plays a vital role. Most preserved foods, including corn flakes and biscuits, have so much salt that could offset drug effects very effectively. Physical exercise is another important factor controlling blood pressure.(8) Drugs would give a false sense of security to the patient that he/she could forget the other rules of the game. Even our logic that blood pressure is the product of cardiac output and peripheral resistance is flawed as there are no straight blood vessels in the body. The Ohm’s law applies to straight tubes only! That is why beta-blockers that increase the peripheral resistance still reduce blood pressures and alpha-beta blockers are not the panacea for all hypertensives! The unexpected results that have come out of some studies on long term drug use could be due to our faulty linear thinking. Time evolution, what happens to man in future, depends on the total initial state of man-his phenotype, his genotype and his consciousness. Changing the initial state partially need not maintain the effect as time evolves. When one understands this logic everything falls into place in this jigsaw puzzle of hypertension and its control.(9) It is very easy for pharmacologists to get studies done on small populations and then help write guidelines based on them but, very difficult for practising physicians in real life situations.(10, 11, 12) The more number of tablets the patient gets less is the compliance in real life, unlike in controlled studies. Even controlled studies did, at times, show marginally elevated number of deaths compared to the projected number of deaths, forcing studies to curtail their duration! Yours ever, Bmhegde References: 1) Hegde BM. Hypertension-the other side of the coin. Jr. Assoc. Physi. India 1988; 36: 324-330. 2) Fries ED. Effects of treatment on morbidity in hypertension. JAMA 1967; 202: 116-121 3) Andersson OK, Almgren T, Persson B, et. al. Survival in treated hypertensives after two decades follow up. BMJ 1998; 317: 171. 4) Alderman MH. The case for caution in the treatment of mild hypertension. Jr. of Hypertens 1986; 4(suppl V) 5537-5540 5) Firth FR. Chaos-predicting the unpredictable. BMJ 1991; 303: 1565-1568. 6) MRC Working Group: Principal results. BMJ 1985; 291: 97-104. 7) Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors in the pathogenesis of cardiovascular disease and implications for therapy. Circulation 1999; 99: 2192-2217. 8) Erol B and Beaglehole R. Exercise for hypertension. Lancet 1993; 341: 1248-1249. 9) Strandberg TE, Salomaa MD, Nukkarinen VA, et. al. Long term mortality after five years multi-factorial primary prevention of cardiovascular diseases in middle aged men. JAMA 1991; 266: 1225-1229. 10) Kopelman RI and Dzau VJ. Trends in treating mild hypertension-a word of caution. Arch. Intern. Med 1985; 14547-49. 11) Bloom BS. Daily regimen and compliance with treatment. BMJ; 2001:323: 647. 12) Schaffer MW. Chaos in living systems. Science 1989; 243: 675-676. Competing interests: None declared |
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