Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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A flawed model?
- Malcolm E Kendrick (3 September 2004)
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Is it disease-mongering?
- Dr. Herbert H. Nehrlich (3 September 2004)
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Good but missed the point
- Iain Bonavia (3 September 2004)
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Treating Hypertension - The full cost of chasing targets
- Elwyn Davies (7 September 2004)
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Estimating individual benefit is the problem
- john sharvill (8 September 2004)
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Something missing?
- Chris E Nancollas (9 September 2004)
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Increasing medicalisation of life
- Steve D Connolly (9 September 2004)
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Re: Good but missed the point
- Dominic J Stevens (16 September 2004)
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Clarifications required on Guidelines for Treatment of Hypertension
- Palepu S.R.K. HARANATH (10 May 2005)
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Re: Clarifications required on Guidelines for Treatment of Hypertension
- Dr. Herbert H. Nehrlich (12 May 2005)
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Re: Re: Clarifications required on Guidelines for Treatment of Hypertension
- Palepu S.R.K. Haranath (12 May 2005)
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Malcolm E Kendrick, Medical Director Adelphi Lifelong Learning Adelphi Lifelong Learning, Adelphi Mill Bollington SK10 5JB
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Within an excellent editorial Campbell and Murchie repeat an 'old saw' about blood pressure. 'Compelling evidence has existed since at least 1990 that increasing blood pressure is associated with an increasing risk of cardiovascular events, with no threshold to the relation.' If I may quote an editorial from the European Heart Journal (Oct 2000) 'But it is often forgotten than when a study reports a linear (or any other) relationship between two variables it is not the data itself, but the model used to interpret the data, that it yielding the relationship.' The authors of this review went back to the original Framigham data (which underpinned the creation of the orignal linear logistic model) to find out if model actually 'fitted' the data, and did not merely smooth away important features of the data. Their findings were that 'Shockingly, we have found that the Framingham data in no way supported the current paradigm to which they gave birth. In fact, these data actaully statistically reject the linear model.' However,the linear model is the one used by everyone to underpin guidelines on blood pressure lowering. What the figures - without modelling - appear to tell us is that the true relationship between blood pressure and cardiovascular events is one that does have clear thresholds. Therefore, all guidelines in this area are wrong. [1] Port S et al. 'There is a non-linear relationship between mortality and blood pressure. EHJ (2000) 21, 1635 - 1638 Competing interests: None declared |
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Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
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New targets for blood pressure as for cholesterol, very difficult to achieve but 'desirable'. Dialogue with the patient to ensure a better outcome. All this means to me that brainwashing of the patient about the absolute necessity for intervention is encouraged and will, so one assumes, bring about better 'compliance'. Before I take 4 or 5 pills to lower my blood pressure to some arbitrary goal I will remind myself of the old gold standard that was in place during my father's generation. 100 plus your age for systolic. For a politically correct diastolic reading I would slightly alter my lifestyle, and, while doing that, stop worrying. Plenty of evidence is alleged to exist that the lowering of blood pressure by medication is beneficial. I wish someone would send me this evidence. Competing interests: None declared |
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Iain Bonavia, General Practitioner Tennant Street Medical Practice, Stockton-on-Tees, TS18 2AT
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I enjoyed reading Campbell and Murchie's article on treating hypertension with guidelines and felt that their points about involving the patient are crucuial. However I feel that they have sadly missed out one of the key drivers for GPs in England and Wales to be aggressivley treating Hypertension to targets which is the Quality and Outcome framework of the new GMS contract (GMS2). There are 20 points on offer for recording a blood pressure result in our hypertensives, but a massive 56 for 70% of the hypertensives having a blood pressure of 150/90 or less. Combining this with another 53 points for blood pressure recording and targets in patients with coronary heart disease, strokes and diabetes mellitus (with a lower treatment target), this is a massive financial drive for GPs to treat their hypertensives. As "points mean pounds" it will be interesting to review the impact of the GMS2 on the level of blood pressure management in General Practice. I may be cynical but I feel it may have more impact that the Guidelines. However surely that is the intention of the Quality and Outcomes Framework anyway. Competing interests: None declared |
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Elwyn Davies, GP Cheddar Medical Centre, Roynon Way, Cheddar BS273NZ
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Many thanks to Drs Campbell and Murchie for an excellent editorial which recognises that GPs deal principally with individuals not populations and certainly not the selected and disciplined populations of clinical trials. I agree that present blood pressure target levels, as with so many others, are unachievable for most patients, not least because if we believe in the idea of well informed patients being properly involved in decisions about their care this has to include their right to say no. Unfortunately the pressure to chase targets is relentless and comes from many sources, ranging from the well meaning, like researchers, epidemiologists and our specialist colleagues, to the more dubiously motivated such as policy makers whose survival depends on simplifying complex arguments into vote grabbing Grand Ideas. More worrying is the financial incentive to chase targets which has been introduced through the new GP contract. I cannot think of many more chilling questions to be asked by a patient than 'Are you doing this for the money, doctor?'. If as a profession we have any ambitions left to preserve the level of trust we've enjoyed from patients for so many years then people need to know that we are still capable of recognising what makes them unique. Sometimes this might mean ignoring a target. It certainly means ignoring the money. Competing interests: None declared |
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john sharvill, GP Deal England CT147au
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This article needs to be read in conjunction with the letters on hypertension in the same issue. On the one hand the BHS quotes the 'evidence' from usually sponsored trials. On the other GP.s are increasingly anxious about the pressure to make whole subsets of the population multiple pill takers. If one goes back to the MRC hypertension trials clear NNT were published. Now we tend to see figures of marginal risk reduction rather than absolute therbye increasing the percieved benefit. It was therefore enlightening to read that the first drug provides most benefit. After a patient is on three anti-hypertensive agents it would be very interesting to know the NNT for a benefit in adding a fourth. This month also carries an update in cardiovascular medicine in the British journal of General Practice highlighting the fact that the risk factors on terms of cholesterol over estimate the risk for most of the UK population. These tables though contribute to the fact that statins are now our practices highest prescribing cost. Finally is the British Hypertension society sponsored or independent of the pharmaceutical industry? Competing interests: None declared |
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Chris E Nancollas, GP Newnham, Glos GL14 1BE
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Sir, It is fascinating to observe how the hypertension debate always resolves into the same two camps. In one you have the academics, whose Holy Grail is more protocols and guidelines, and in the other the GP's, who stubbornly maintain that perfect control is impossible. As one of the latter, I welcome this well balanced editorial. Two things stand out. General practice is a broad and disputatious church, yet there is remarkable unanimity on the difficulties of treating hypertension. Surely this fact is significant? Perhaps it indicates that there is an unknown factor, not necessarily a scientific one, which prevents the mastery of this disease. It would certainly indicate why guidelines and protocols never seem to get to the heart of the matter, and why this feeling is shared amongst doctors of all specialities. Secondly, it is nice to see the object of the exercise, the patient, getting a mention at last. Half the problem with treating hypertension is tailoring the medication to the individual siiting on front of you. The other problem is trying to explain to the patient what is going on. How many hypertensive patients get a genuine risk/benefit analysis of their disease? And could any of us actually do it? Perhaps what we need is a treatment/no treatment/percentage benefit of treatment chart which we could discuss with the patient. You never know, it might do wonders for the drugs bill. Chris Nancollas Competing interests: None declared |
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Steve D Connolly, GP Principal Priory Medical Centre L6 4EW
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I think many GPs across the country will find resonance with Campbell and Murchie's views. Our otherwise well patients come to see us, have their blood pressure measured and many start on a medical treadmill of investigations, "treatments" and side effects. These otherwise well people become ill - "I suffer with high blood pressure, Doctor". They develop swollen ankles, lethargy, impotence, headaches, hot flushes, gout, electrolyte imbalances etc. They have blood tests and ECGs. For all of the iatrogenic suffering, most people will not benefit from lowering of their blood pressure, or cholesterol for that matter. The only people who are benefitting from this are the 1 in however many who are needed to treat, the researchers making a name and a career for themselves and of course the big drug companies. But, I have to go now and meet my Quality Framework targets! Competing interests: None declared |
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Dominic J Stevens, Salaried GP south Lambeth Rd practice SW8 1UL
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You may not be cynical enough. Management of hypertension will be influenced by targets, but the measurement and recording of measurement could be distorted by targets. Or certainly will be? Competing interests: None declared |
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Palepu S.R.K. HARANATH, Retired Professor 22, Alka, 15th Road, Santacruz (West) MUMBAI 400 054 INDIA
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Sir, It is for patients to decide and not targets.1 With distressing side effects, no guarantee of extended life or cause of death, patients and practitioners shy away from drug treatment for hypertension and expect satisfactory answers. Is hypertension reversible when the stress is removed? With normal BP after long treatment can drugs be reduced or paused? Aggressive drug treatment for life blunts BP regulation with no end point or specificity, as in immunization. Hypertension is elevation of arterial blood pressure (BP) above an arbitrarily defined normal value.2 BP record is subjective, not precise and variable. Statistics with this variable numeral are error prone.3 Patients’ records are from a vulnerable segment of population not normal. An epidemic of hypertension is forecast with narrowed definitions. Normal values need to be determined afresh in healthy persons including elders. Most medical staff will be ‘prehypertensives’! The diagnosis ‘Prehypertension’ itself raises BP. Those with hypertension alone without risk factors should be studied if it is result or cause of vascular sclerosis / endothelial changes. ‘Risk of developing hypertension’ is equated to ‘risk of CVD’. All- cause mortality, coronary heart disease and stroke mortality were similar in hypertensive and normotensive men during the first decade, but increased thereafter despite continuous good blood pressure control. Hypercholesterolemia is the major risk factor for coronary thrombosis and hypertension for strokes.4 In 1 million participants with 12% mortality, stroke deaths (1.2%) are 1/3 of deaths due to ischemic heart disease (3.4%).5 Systolic BP rises always more than diastolic and not readily controlled by drugs. Not all agree with cut-off value 140 mm for hypertension for all adults. Dr. P.S.R.K. Haranath, MD, DSc
References: 1. Campbell NC, Murchie P. Treating hypertension with guidelines in general practice. Patients decide how low they go, not targets. BMJ 2004;329:523-524 2. Brody TM Antihypertensive drugs In Wingard LB, Brody TM, Larner J, Schwartz A. ed. Human Pharmacology – Molecular to clinical. Wolfe Mosby, London 1991, p167 3. Green BB, Kaplan RC, Psaty BM. How do minor changes in the definition of blood pressure control affect the reported success of hypertension treatment? Am J Manage Care. 2003; 9: 219-24 4. Andersson OK, Almgren T, Persson B, Samuelsson O, Hedner T, Wilhelmsen L. Survival in treated hypertension: follow up study after two decades BMJ 1998;317:167-171 5. Lewington S, Clarke R, Quizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million: in 61 prospective studies. Lancet. 2002; 360(9340): 1903-13 Competing interests: None declared |
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Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
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Professor Haranath's comments concerning Hypertension are valid in principle. The recently revised margins for what constitutes normal fly in the face of common sense. It is also true that the risks of hypertension treatment far outweigh the benefits. Professor Haranth's mention of the following however, is not supported by facts, inspite of the fact that the bogeyman is alive and well. Quote: "Hypercholesterolemia is the major risk factor for coronary thrombosis and hypertension for strokes...." The cholesterol hypothesis is a truly dead horse and it has started to smell badly enough for the common people to notice. As to hypertension, a sensible guideline would be a return to the past: 100 plus your age. Works for me. Competing interests: None declared |
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Palepu S.R.K. Haranath, Retired Professor 22, Alka, 15th Road, Santacruz (West), MUMBAI 400054 INDIA
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I am glad to note the response of Dr. Herbert H. Nehrlich. I am merely quoting the conclusion of Andersson OK, Almgren T, Persson B, Samuelsson O, Hedner T, Wilhelmsen L. Survival in treated hypertension: follow up study after two decades BMJ 1998;317:167-171, regarding hypercholesterolemia and ischaemic heart disease I wish that study of Hypertension without other risk factors deserves a detailed study in all aspects both to determine the normal BP levels in elders and to glean the relationship - result or Cause - between Hypertension and vascular sclerosis and endothelial changes. With antitobacco measures gaining ground, persons with hypertension alone seek /need special attention. Competing interests: None declared |
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