Law's Floor :- re: Reply to rapid responses on bmj.com
Rapid response to:
Research
Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies
Law's Floor :- re: Reply to rapid responses on bmj.com
Law persists in defending his contention that benefits accrue across
his assembled RCTs of BP-lowering, down to a level of 110mmHg. Such an
optimistic Public Health perspective fits neatly with the epidemiology of
the wide-ranging correlation of pre-treatment BP to CVD risk, but lacks
any jobbing-GP reality check.
So far as I can tell Law's enthusiasm takes no account of
1 . the diminishing size of benefit at lower CVD risks, and
2. the HARMS of BP-lowering drugs, across the board, and the lower
the BP.
I apply the guidelines that exhort me as a GP to lower the BP below
140/85 in certain high-risk patients ( eg: CKD / high CVD-Risk / Older
Diabetics /recent MI ). This I believe worthwhile because HIGH-CVD-RISK
is accompanied by larger absolute benefits of treatment, which must
outweigh the harms of BP-lowering drugs to justify my prescription. Low-
cvd-risk patients will likely suffer more harm than good, as first mooted
in the J-shaped curve controversy of the 1970s.
If Law continues to believe that polypill-style approaches should
reach deeper into 'healthy' populations, without limit, he needs to
examine the current Aspirin controversy, which clearly show that low-risk
patients ( even Doctors aged 60 such as myself) suffer roughly as much
harm as benefit from that drug.
We need to row back, using Actual CVD Risk should be a key measure.
Law should recognise the need for a floor.
Yours, etc
sam lewis
REF:
Aspirin in the primary and secondary prevention of vascular disease:
collaborative meta-analysis of individual participant data from randomised
trials
The Lancet, Volume 373, Issue 9678, Pages 1849 - 1860, 30 May 2009
Rapid Response:
Law's Floor :- re: Reply to rapid responses on bmj.com
Law persists in defending his contention that benefits accrue across
his assembled RCTs of BP-lowering, down to a level of 110mmHg. Such an
optimistic Public Health perspective fits neatly with the epidemiology of
the wide-ranging correlation of pre-treatment BP to CVD risk, but lacks
any jobbing-GP reality check.
So far as I can tell Law's enthusiasm takes no account of
1 . the diminishing size of benefit at lower CVD risks, and
2. the HARMS of BP-lowering drugs, across the board, and the lower
the BP.
I apply the guidelines that exhort me as a GP to lower the BP below
140/85 in certain high-risk patients ( eg: CKD / high CVD-Risk / Older
Diabetics /recent MI ). This I believe worthwhile because HIGH-CVD-RISK
is accompanied by larger absolute benefits of treatment, which must
outweigh the harms of BP-lowering drugs to justify my prescription. Low-
cvd-risk patients will likely suffer more harm than good, as first mooted
in the J-shaped curve controversy of the 1970s.
If Law continues to believe that polypill-style approaches should
reach deeper into 'healthy' populations, without limit, he needs to
examine the current Aspirin controversy, which clearly show that low-risk
patients ( even Doctors aged 60 such as myself) suffer roughly as much
harm as benefit from that drug.
We need to row back, using Actual CVD Risk should be a key measure.
Law should recognise the need for a floor.
Yours, etc
sam lewis
REF:
Aspirin in the primary and secondary prevention of vascular disease:
collaborative meta-analysis of individual participant data from randomised
trials
The Lancet, Volume 373, Issue 9678, Pages 1849 - 1860, 30 May 2009
Competing interests:
Harms versus Benefits
Competing interests: No competing interests