Surprisingly little has changed since the time of the psalmist!
The life expectancy of a male at 75 is less than 10 years according
to government statistics. (2) Currently in our practice of 10,100
patients, only 3.43% get beyond 80 years, with 0.44% getting past their
90th birthday.
The British Hypertension Society states that all whose risk is 20% or
over should be started on statins, aspirin and an antihypertensive up to
the age of 80 years. (3) Hence a 75 year old male, life-long non-smoker,
non-diabetic with a BP of 140/90, cholesterol of 5 and an HDL of 1 would
be put on triple therapy, rather than congratulated on his good health!
The Whitehall study found, “After more than 25 years of follow up of
civil servants aged 40-69at entry to the study, employment grade
differences still exist in total mortality and in nearly all specific
causes of death. The main risk factors (cholesterol, smoking, systolic
blood pressure, glucose intolerance and diabetes) could only explain one
third of this gradient.” (4)
Recent articles by Brindle et al on the inaccuracy of the Framingham
score sheds doubt on its usefulness. (5)
A review article in the British Journal of General Practice commented
that the best predictor of cardiac death was age. (6)
So do we use a risk scoring system which gives results with a
confidence interval of 50% either way, depending on local prevalence and
social class – remembering that ethnicity and family history add further
major inaccuracies?
The push to provide primary prevention based on risk scores is surely
flawed. There is also the issue of informed consent. If we accept that the
risk of dying for each human being is 100%, there are only three main
variables of death – where, when and how. The “where” is about geography
and social systems, the “when” and “how” are the areas that medicine tries
to influence. How we die tends to be related to when we die. As a child
the main risks are from congenital inheritance, infection, some cancers
and violence (accidental and non accidental). If a young male dies, it is
most likely to be from violence (accidental, non accidental or self
inflicted), a young woman (thinking globally) from child birth. An elderly
person will die from cardiovascular disease, cancer or “bronchopneumonia”
(a euphemism often used to describe the death of an octogenarian with
senile dementia in residential care). If one reduces the risk of dying
with cardiovascular disease, because the maths must add up, presumerably
more people will die of cancer. Ravenskov et al (7) in their article
suggest that this is true – either as a direct effect of statins
themselves, or because mathematically one has to die from something!How
often do we discuss this with patients in the final decades of their
natural life?
There is a seeming madness in the way Western Medicine is developing.
Increasing polypharmacy in an aging population is a risk laden course of
action, which promises few real benefits.
3) Williams B. et al. Guidelines for the management of Hypertension:
report of the fourth working party of the British Hypertension Society
2004 – BHS IV. Journal of Human Hypertension (2004) 18, 139-185
4) van Rossum et al (2000) Employment grade differences in cause specific
mortality: a 25 year follow up from the first Whitehall Study quoted in
“Risk Matters In Healthcare” K Mohanna and R Chambers Radcliffe Medical
Press (2001)
5) Brindle P et al. The Accuracy of the Framingham risk-score in different
socio-economic groups: a prospective study. BJGP 2005 Vol 55 Number 520
Rapid Response:
Its all about risk!
Dear Sir,
“The span of our life is seventy years –
eighty for those who are strong –
but their whole extent is anxiety and trouble,
they are over in a moment and gone.” (1)
Surprisingly little has changed since the time of the psalmist!
The life expectancy of a male at 75 is less than 10 years according
to government statistics. (2) Currently in our practice of 10,100
patients, only 3.43% get beyond 80 years, with 0.44% getting past their
90th birthday.
The British Hypertension Society states that all whose risk is 20% or
over should be started on statins, aspirin and an antihypertensive up to
the age of 80 years. (3) Hence a 75 year old male, life-long non-smoker,
non-diabetic with a BP of 140/90, cholesterol of 5 and an HDL of 1 would
be put on triple therapy, rather than congratulated on his good health!
The Whitehall study found, “After more than 25 years of follow up of
civil servants aged 40-69at entry to the study, employment grade
differences still exist in total mortality and in nearly all specific
causes of death. The main risk factors (cholesterol, smoking, systolic
blood pressure, glucose intolerance and diabetes) could only explain one
third of this gradient.” (4)
Recent articles by Brindle et al on the inaccuracy of the Framingham
score sheds doubt on its usefulness. (5)
A review article in the British Journal of General Practice commented
that the best predictor of cardiac death was age. (6)
So do we use a risk scoring system which gives results with a
confidence interval of 50% either way, depending on local prevalence and
social class – remembering that ethnicity and family history add further
major inaccuracies?
The push to provide primary prevention based on risk scores is surely
flawed. There is also the issue of informed consent. If we accept that the
risk of dying for each human being is 100%, there are only three main
variables of death – where, when and how. The “where” is about geography
and social systems, the “when” and “how” are the areas that medicine tries
to influence. How we die tends to be related to when we die. As a child
the main risks are from congenital inheritance, infection, some cancers
and violence (accidental and non accidental). If a young male dies, it is
most likely to be from violence (accidental, non accidental or self
inflicted), a young woman (thinking globally) from child birth. An elderly
person will die from cardiovascular disease, cancer or “bronchopneumonia”
(a euphemism often used to describe the death of an octogenarian with
senile dementia in residential care). If one reduces the risk of dying
with cardiovascular disease, because the maths must add up, presumerably
more people will die of cancer. Ravenskov et al (7) in their article
suggest that this is true – either as a direct effect of statins
themselves, or because mathematically one has to die from something!How
often do we discuss this with patients in the final decades of their
natural life?
There is a seeming madness in the way Western Medicine is developing.
Increasing polypharmacy in an aging population is a risk laden course of
action, which promises few real benefits.
1) Psalm 90 vs 10
2) http://www.gad.gov.uk/Life_Tables/Notation.htm
3) Williams B. et al. Guidelines for the management of Hypertension:
report of the fourth working party of the British Hypertension Society
2004 – BHS IV. Journal of Human Hypertension (2004) 18, 139-185
4) van Rossum et al (2000) Employment grade differences in cause specific
mortality: a 25 year follow up from the first Whitehall Study quoted in
“Risk Matters In Healthcare” K Mohanna and R Chambers Radcliffe Medical
Press (2001)
5) Brindle P et al. The Accuracy of the Framingham risk-score in different
socio-economic groups: a prospective study. BJGP 2005 Vol 55 Number 520
6) Fahy T, Schroeder K, Cardiology BJGP 2004 Vol 54 Number 506
7) Ravnskov U, Rosch P et al. Should we lower cholesterol as much as
possible? BMJ 2006; 332: 1330-2
Competing interests:
None declared
Competing interests: No competing interests