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HEAD TO HEAD: Simon Capewell Will screening individuals at high risk of cardiovascular events deliver large benefits? No BMJ 2008; 337: a1395 [Full text]

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Why Fight 20th Century Battles?

Michael A Soljak   (29 August 2008)

Whose battle are we fighting, anyway?

Hegde BM   (9 September 2008)

Are treatments of those identified by screening really the best?

Raymond G Holder   (10 September 2008)

Targeting, community, and a top down aporach is needed to improve health

David J Kinshuck   (7 October 2008)

Reduction of incidence of Cardiovascular disease

Harald M Lipman   (8 October 2008)

Screening for Original Sin

J. david leopold   (9 October 2008)

Why Fight 20th Century Battles? 29 August 2008
Michael A Soljak, Postgraduate researcher Imperial College London, Charing Cross Campus, LONDON W6 6RP Send response to journal: Re: Why Fight 20th Century Battles?	In his defence of a "public health" approach to CVD risk reduction Capewell makes a number of claims which are not verifiable. For example, he states that "the medical treatment of high risk people typically costs £5000-£100 000 per quality adjusted life year (QALY)". However one reference he quotes, the recent HTA review (1), only modelled cost- effectivness between 0.5-3% absolute CVD risk, which is much lower than the 20% cutoff in the planned screening programme. The latter delivers cost-effectiveness well within NICE's current notional limits. The other reference quotes his own paper (2), published in 2007, which inexplicably uses statin costs from 2000 (£387 per year). This is much higher than current costs for generic statins. Capewell worries about "screening failures" in deprived populations. The lack of a high-risk CVD screening programme is the greatest screening failure, as it allows the inverse care law to operate untrammelled, as the better-off capture the health benefits at their local pharmacy. Ideology is not a rationale for using one approach or the other for CVD risk reduction. Cost-effective (and now relatively cheap) strategies should be pursued whatever their origin. References (1) Ward S, Lloyd JM, Pandor A, Holmes M, Ara R, Ryan A, et al. A systematic review and economic evaluation of statins for the prevention of coronary events. Health Technol Assess 2007;11(14):i-iv. (2) Fidan D, Unal B, Critchley J, Capewell S. Economic analysis of treatments reducing coronary heart disease mortality in England and Wales, 2000-2010. QJM 2007;100:277-89. Competing interests: None declared
Whose battle are we fighting, anyway? 9 September 2008
Hegde BM, Editor in Chief, Journal of the Science of Healing Outcomes. Mnaglore-575004, India Send response to journal: Re: Whose battle are we fighting, anyway?	Dear Editor, I must congratulate Prof. Capewell for his correct analysis. The screening industry is, in fact, fighting the unseen beneficiaries’ battle. Scientifically, one can never predict the future of a dynamic individual using a few phenotypic parameters at any given time. Time evolution depends on the total initial knowledge of the organism, which is impossible in our present knowledge. (1) (2) We have been predicting the unpredictable future in the arena of CVS risk hypothesis. That should cancel all other arguments in favour of screening for any disease in its pre-symptomatic stage. Zukel, Paul and Schnaper’s 1981 paper on MRFIT was analysed by Professor Roger Sherwin thus: “In other words, they found that changing the "risk factors" does not apparently change the risks. This necessarily means that the "risk factors" are not as important as was thought. Indeed, it should be concluded that the "risk factors" were no such thing, at least as far as this trial is concerned.” (3) Cost effectiveness is a minor issue. If one goes by the cost effectiveness alone, one can never support heroic things like heart and liver transplants or, for that matter, even bone marrow transplants. Let me remind the readers that the State of Oregon in the US found out that the cost of one bone marrow transplant in a terminally ill leukaemic child would cost as much money as is needed to manage 1000 pregnant women anti- natally as also their offspring through infancy. That was the genesis of the “Oregon Law” that prohibits bone marrow transplants for terminally ill children at tax payers’ cost! That law was condemned by many in the US only to be followed by many other States sooner than later! The rich can get anything that they want, anyway. “He who hath shall be given”! I would like to reiterate that most of the long term intervention studies did show that there is negligible, if any, benefit from long term screening and intervention efforts, both in case of blood pressure, cholesterol and sugar lowering. All of them did show some benefit in relative risk reduction but not in absolute risk reduction. (3) These studies did not take into account the NNT (number needed to be treated unnecessarily) what with their prohibitive cost in terms of money and lives lost due to ADRs! ADRs (Adverse Drug Reactions) have become one of the leading causes of death. (4) (5) I think time has come to rethink our strategy of screening to intervene in the “well” and think of promoting the overall health of the population-the wellness concept. “Knowledge advances NOT by repeating known facts, but by refuting false dogmas.” Routine screening of the apparently healthy has been a dangerous dogma for too long which has damaged human health as also emptied the tax payers’ pockets in the NHS. (6) Yours ever, bmhegde References: 1) Firth WJ. Chaos-doctors predicting the unpredictable. BMJ 1991; 303: 1565-1568. 2) Hegde BM. Chaos- a new concept in science. Jr. Assoc. Physicians India 1996; 44: 167-68. 3) Sherwin, R. W., Kaelber, C. T., Kezdi, P., Kjelsberg, M. O. and Thomas, H. E.: The Multiple Risk Factor Intervention Trial (MRFIT) II. The development of the protocol. Preventive Medicine 1981; 10:402-425. (and Uffe Revneskov in BMJ 18th June 2002) 4) Nuovo J, Melnikow J, Chang D. Reporting Number Needed to Treat and Absolute Risk Reduction in Randomized Controlled Trials. JAMA 2002;287:2813-4 5) McCormack J and Greenhalgh T. Seeing what you want to see in research. BMJ 2000; 320: 1720-1723. 6) Stewart-Brown S, Farmer A. Screening could seriously damage your health. BMJ 1997; 314: 533. Competing interests: None declared
Are treatments of those identified by screening really the best? 10 September 2008
Raymond G Holder, Retired engineer BH9 3NF Send response to journal: Re: Are treatments of those identified by screening really the best?	Prof. Capewell has shown the unsatisfactory state of affairs brought about by screening programmes. Screening suggests that current knowledge of CVD risks and the treatment is at an ultimate peak, and that the methods used to treat those determined to be at risk are also beyond question, but is this really the truth? Though large sums have been spent on the part which lipids are thought to play in CVD, there are many who question this approach which takes no account of the undoubted part which raised homocysteine plays, nor the view that raised LDL cholesterol is probably a symptom, and not a cause. But are the treatments for CVD risk and for hypertension, while reducing certain numerical values, really improving the life of the subject? The Professor makes the point that quality of life often often decreases with the treatments which are meted out.I have expressed my views on statin use many times here, the outcome only being seen to be on cholesterol levels, the unseen, but damaging effects on metabolism in the mitochondria are disregarded as irrelevant. I am concerned just as much by the the side effects of anti- hypertensive drugs, which only lower blood pressure, with no mechanism to cease that action when the optimum level is reached. The effects on the patient are dangerous, older people falling over in the home, or worse, in the street, with all the dangers to life and limb which attend such events. It is bordering on it being a criminal action to put them into this situation. I have seen this so many times and experienced the symptoms myself, though fortunately recognising them and sitting down until normality is resumed. The basic reason for much hypertension in those over 50 is not recognised. Coenzyme Q10 production is now falling, and energy (ATP)supplies to all parts of the body reduce. The heart has a very large need for energy to maintain its pumping action, particularly in the most demanding filling phase, and any shortfall results in back pressure on the outgoing blood pulse, raising the pressure. Dr Peter Langsjoen, whose work is readily available via Google, regularly finds the value, in his hospital situation, of Q10 supplementation to improve this heart action, most normal anti- hypertensive drugs becoming unnecessay in the process. I used to take three drugs, and now, with Q10 taken regularly, need only a nitrate vasodilator. the vascular system no longer has its pressure control mechanism set to "lower at any price", and regulates in its usual manner. Side effects, if any, are usually due to the Q10 putting things right, and the anti-hypertensive carrying on its role regardless of the fact that it is pushing things too far. But Q10 seems to have a taboo put upon it by the drugs industry, it is not even in the Formulary, although world-wide sales of it are now at very high levels, and the Japanese manufacturers have opened a new plant in USA. The cost, once fairly large, is now much reduced, and well within the range necessary for continuous use. More to the point, it is not a drug, but a normal body component, and not in any way likely to cause damage. I have taken it now for over 5 years with no problems, and it continues to be effective. Is there no-one who will undertake urgent research into the use of this, (and similar,) most useful and safe substance, or is the overbearing hand of drug industry protectionism being allowed to leave the public with second best solutions to its problems. Competing interests: Statin damaged patient
Targeting, community, and a top down aporach is needed to improve health 7 October 2008
David J Kinshuck, Associate Specialist, Ophthalmology, Good Hope Hospital, B75 7RR Send response to journal: Re: Targeting, community, and a top down aporach is needed to improve health	Surely both a targeting strategy (Jackson) and a community based strategy (Capewell) will be needed. But to deliver large benefits, a top down approach must be part of any strategy, and without this cardiovascular events will continue. In Birmingham we have the second highest obesity rates of any large UK city, and it is no coincidence that we have very low cycling and walking rates. Indeed, fewer still women cycle, especially in deprived Asian communities with the highest diabetes rates in the UK. Those of us who participate in the city’s health task forces are totally frustrated by the Council’s lack of action to address these issues. Simple and cheap measures, such as pan-city 20 mph limits speeds to make cycling and walking safe, opening up derelict land (that was due to be developed but due to lack of money cannot at present) to make it into sports areas , are not implemented. Cycling rates in London and many other European cities have increased with such measures. But the petrol heads rule here, and unless Government legislation is changed nothing will happen. We need Council funding tied to action…no cycling increase, no funding; stopping planning permission for large numbers of fast food outlets, increasing play areas, as examples. As Jackson said, it is important to target high risk cases. We need to identify the diabetes before the retinopathy is present. We also need a population approach that Capewell suggests. But in addition we need central Government to use the carrot and stick approach ruthlessly with Councils, to ensure the fast food, little exercise, and car culture will change, and only then will health improve. Competing interests: None declared
Reduction of incidence of Cardiovascular disease 8 October 2008
Harald M Lipman, Retired Physician The Dutch House NW3 6NY Send response to journal: Re: Reduction of incidence of Cardiovascular disease	We have read with interest the persuasive articles “Will screening individuals at high risk of cardiovascular events deliver large benefits” in terms of reductions in morbidity & mortality. Cardio & cerebrovascular disease are Worldwide problems, in both developed and developing countries – causing 17 million deaths annually and necessitating costly medical care for those 20 million who survive1. The causative factors are largely known – genetic, possibly severe stress, possibly infective and certainly lifestyle factors, such as tobacco, excessive salt and saturated fats, obesity and inadequate physical activity. In some parts of the World excessive alcohol intake is an additional very significant factor. All these lifestyle factors are potentially modifiable. Hypertension, hypercholesterolaemia and diabetes all further increase the risks. All these are treatable to a greater or lesser degree. The question is how best to reduce this multifactorial problem in an effective and cost effective manner. We have read the views of the proponents of the two main approaches – population-wide measures to reduce risk factors or targeting high risk individuals. Both approaches claim degrees of success. No single approach, or combination of approaches could ever be 100% effective. No one approach should preclude another. We feel, in any target population, prevention is certainly better than cure. However, those already damaged must be appropriately treated and where possible have their risk of further damage reduced. Those, so far undamaged, but at risk, must be identified and measures be taken to reduce their risk of developing damage in later life. At national levels steps must be introduced to reduce risk factors by legislation, such as tobacco reduction by increased taxation and introduction of smoke-free areas, plus well-designed health education programmes for the general public and in particular children. Individual total risk assessment, even though at present imperfect, should be introduced for all men (and women), aged 40 upwards 2. Those with a 10 year risk >10% should be encouraged to take daily low-dose aspirin and those with a risk >20% in addition should take daily statins 3. This must be combined with professionally monitored lifestyle intervention . Surely, it is better to reduce this major problem by all means available, rather than concentrating on any one or other approach? Dr Harald M Lipman Executive Director International Cardiac Healthcare & RiskFactor Modification References 1. WHO Cardiovascular Disease Prevention & Control 2006 2. Joint British Societies guidelines on prevention of CVD in clinical practice 2005 3. Primary prevention in the adult American Heart Association 2008 Competing interests: Director, International Cardiac Healthcare & RiskFactor Modification (ICHARM)
Screening for Original Sin 9 October 2008
J. david leopold, Consulatnt Physician swansea sa4 6nl Send response to journal: Re: Screening for Original Sin	The polemic is important. But with due deference to the illustrious authors, seems easily resolved, if we can put aside Illitch for a moment. Screening for, say 20% CVS risk will miss the vast majority of CVS disease, and avoidable deaths and morbidity. The screening will cost money which could otherwise be spent on prevention. We have excellent data to support the concept of the polypill, which would be available cheaply or free to all over the age of say 55. But we need to be pragmatic, and escape from the notion that normal is healthy. Kind regards david Competing interests: None declared