Intended for healthcare professionals

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

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1665 (Published 19 May 2009) Cite this as: BMJ 2009;338:b1665

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

27 June 2009
L Sam Lewis
GP
Surgery, Newport, Pembrokeshire, SA42 0TJ