This is a really interesting discussion, but I would like to add one more factor to the challenge of making global risk assessment useful in shared decision making, that is the education of those using the risk assessment to understand the factors and how they contribute to the final global assessment.

Using the CV risk as an example: there may be two patients each with a global risk of 25%, one who is smoking 40 cigarettes per day, and another non-smoker whose major factor influencing risk is their age. The clinician must understand this in order to hold an informed conversation with the patient on how best to proceed in terms of treatments and lifestyle intervention.

A key factor for this is the implementation of these tools in the clinical environment in a manner that will support this type of informed shared decision making.

Cheers,

Geoff Schrecker
MB BChir MBCS FRCGP FFCI

Retired GP
Clinical Informatician
RCGP Clinical Champion for Patient Data Choices


Mail signed using GPGMail
Public key available from hkps://hkps.pool.sks-keyservers.net



> On 19 Dec 2017, at 08:17, McCormack, James <[log in to unmask]> wrote:
> 
> Much of health is about managing expectations and helping people if they have incorrect assumptions - you are correct, many risks can be reduced - the issue is that the magnitude of the benefit vs the side effects cost and inconvenience are often of a similar magnitude and everybody has different values and preferences.
> 
> So even if most just want to be told what to do - a bunch don’t - the only way to figure out which group your patient falls into is to have an open discussion about benefits and harms.
> 
> Are you suggesting that patients don’t want that or couldn’t understand that sort of discussion? Not all can but many do in my experience and I believe the evidence supports my observation.
> 
> Thoughts?
> 
>> On Dec 18, 2017, at 11:40 PM, Owen Dempsey <[log in to unmask]> wrote:
>> 
>> Sorry to burst happy bubble.
>> 
>> This doesn't sound like real world medicine for real patients to me. 
>> 
>> Don't most 'patients' assume that risk measurements are offered because there is treatment available to reduce that risk / it doesn't matter how great a communicator you are the patient is unable to imagine being overdiagnosed/treated (taking treatment based on population data that will harm them as an individual) and so is de facto pressured to ask for treatment - equals a happy drugs market. 
>> 
>> Anticipatory care is fundamentally anti democratic and should be a priori distrusted. 
>> 
>> Owen 
>> 
>> On Tue, 19 Dec 2017 at 05:21, McCormack, James <[log in to unmask]> wrote:
>> Thanks Rod - I just wish all (or any) of the diabetes, lipid, HTN guideline groups felt the same way - virtually none of them support or encourage "real” shared decision making and they never will as long as they mandate having specific surrogate treatment thresholds. The only guideline I am aware of that actually supports real SDM is this one “Simplified Lipid Guidelines” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4607330/ and it was written by primary care clinicians and I was somewhat involved.
>> 
>> James
>> 
>> 
>>> On Dec 18, 2017, at 7:52 PM, Rod Jackson <[log in to unmask]> wrote:
>>> 
>>> Hi James – I agree with you. I don’t think you are missing anything and the papers I reference provide excellent empirical evidence for your second point.
>>>  
>>> Cheers Rod
>>>  
>>> From: "Evidence based health (EBH)" <[log in to unmask]> on behalf of "McCormack, James" <[log in to unmask]>
>>> Reply-To: "McCormack, James" <[log in to unmask]>
>>> Date: Tuesday, 19 December 2017 at 1:28 PM
>>> To: "Evidence based health (EBH)" <[log in to unmask]>
>>> Subject: Re: new hypertension guidelines, controversy
>>>  
>>> Hi Juan and Rod  
>>>  
>>> In my mind, I believe the point of making a CVD risk assessment (say a 10 year risk) on an individual patient is so that you can 
>>>  
>>> 1) inform them of their approximate CVD risk
>>> 2) make a reasonable approximation of the theoretical/potential benefit of treatment
>>> 3) discuss the harms of treatment - adverse effects, costs, inconvenience
>>> 4) work with them to make a shared-decision
>>> 5) and then support whatever decision THEY make
>>>  
>>> Whether or not this leads to an increase or decrease in CVD is irrelevant - in my mind shouldn’t the fact that a well informed shared decision was made be the gold standard endpoint that we are looking for. I believe it is totally reasonable for someone to say they would like to reduce their risk by “2%" and accept all the harms but to also say no, that “2%” is not enough given the harms you have mentioned.
>>>  
>>> Or maybe I’m missing something.
>>>  
>>> James
>>>  
>>>  
>>>  
>>> 
>>> 
>>>> On Dec 18, 2017, at 1:31 PM, Juan Gérvas <[log in to unmask]> wrote:
>>>>  
>>>> -thanks for your comments and suggestions, i will consider sending a letter to the journal
>>>> -about the question of the the prospective use of global cardiovascular risk assessment,  Rod, i agree with your point about two risk factors, LDL cholesterol and hypertension, but my point is about the "global" assessment (the aplication of the table of cardiovascular risk)
>>>> -having no formal impact analysis means that global cardiovasular assessment is only a risk assessment and cannot be used for taking decisions; the cardiovascular tables of risk are only tables of risk, no tables of decision
>>>> Translating clinical research into clinical practice: impact of using prediction rules to make decisions. Clinical prediction rules, sometimes called clinical decision rules, have proliferated in recent years. However, very few have undergone formal impact analysis, the standard of evidence to assess their impact on patient care. Without impact analysis, clinicians cannot know whether using a prediction rule will be beneficial or harmful. https://www.ncbi.nlm.nih.gov/pubmed/16461965
>>>> 
>>>> Global  cardiovascular risk assessment in the primary prevention of  cardiovascular disease in adults: systematic review of systematic  reviews. The quality of existing systematic reviews was generally poor and there is currently no evidence reported in these reviews that the prospective use of global cardiovascular risk assessment translates to reductions in CVD morbidity or mortality. http://bmjopen.bmj.com/content/7/3/e013650?rss=1
>>>> -un saludo juan gérvas @JuanGrvas
>>>>  
>>>> 2017-12-18 16:54 GMT+01:00 Bill Cayley, Jr <[log in to unmask]>:
>>>>> I think it's been a great discussion, I think a response letter to JAMA is a good idea, and I also think it would move the discourse forward to keep it in dispassionate terms about the merits of the evidence and the arguments - I don't think either sides are presenting "horrible" points of view. 
>>>>>  
>>>>> Bill Cayley, Jr, MDMDiv  
>>>>> [log in to unmask]
>>>>> [log in to unmask]
>>>>> http://twitter.com/bcayley
>>>>> Work: 715.286.2270
>>>>> Pager: 715.838.7940
>>>>> Mobile: 715.828.4636
>>>>>  
>>>>> A voice of one calling: "In the desert prepare the way for the LORD; make straight in the wilderness a highway for our God." (Isaiah 40:3)
>>>>>  
>>>>> 
>>>>> On Monday, December 18, 2017 9:51 AM, Anoop B <[log in to unmask]> wrote:
>>>>>  
>>>>> 
>>>>> Thank you Juan and Rod for the excellent discussion!
>>>>>  
>>>>> Juan any chance you will submit your reply to the journal formally? You do have some great points and I don't think Dr.Loannidis reply was very convincing. I really think you should.
>>>>>  
>>>>>  
>>>>>  
>>>>> On Mon, Dec 18, 2017 at 12:27 AM, Rod Jackson <[log in to unmask]> wrote:
>>>>>> Hi Juan and all. While I agree with a couple of your points, with respect, I would like to disagree in particular with your point 4 about impact analysis. You state that ‘There is currently no evidence reported in these reviews that the prospective use of global cardiovascular risk assessment translates to reductions in CVD morbidity or mortality.’
>>>>>>  
>>>>>> I believe we actually have some very good evidence that global risk assessment translates into reductions in CVD.
>>>>>>  
>>>>>> Before I mention the two key papers supporting my argument, it is important to point out that it is impossible to conduct a good RCT of a global risk assessment-based intervention versus an individual risk factor-based assessment. There are a number of trials that have tried to do this and they are all seriously flawed, because they are impossible to do without substantial crossover. Also, all of the studies have used poor risk assessment tools that have not been integrated into routine practice workflow so the uptake has been uniformly poor. You should read some of the studies; they really are very flawed. This is not a reflection on the researchers but simply a reflection on an intervention that cannot be practically randomized.
>>>>>>  
>>>>>> In contrast, there are two individual patient meta-analyses of RCTs (references below); one on lipid lowering with statins and the other on blood pressure-lowering that provide compelling evidence on the benefits of CVD risk-based management. In both studies, a CVD risk prediction equation was developed in the control groups and retrospectively applied to all participants at baseline. This in effect resulted in a double blind assessment of a risk-based intervention without any cross-over and both studies demonstrate that participants at higher predicted risk had greater reductions in CVD events than low risk participants and this effect was apparent at different levels of the individual risk factors. Just check out Figure 5 in the statin paper and Figure 4 in the blood pressure paper.
>>>>>>  
>>>>>> Mihaylova B, Emberson J, Blackwell L, et al. The effects of lowering LDL cholesterol with statin therapy in people at low risk of vascular disease: meta-analysis of individual data from 27 randomised trials. Lancet 2012; 380: 581-90.
>>>>>> Sundström J, Jackson R, Neal B, for the BPLTTC. Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet 2014; 384: 591-98.
>>>>>>  
>>>>>> I think we need to look beyond the traditional approach of the ideal RCT when they are impossible to do well, as is the case here. There is also a huge amount of other evidence to support this approach and the totality of the evidence supports a risk-based approach.
>>>>>>  
>>>>>> The relationship between saturated fat consumption and CHD is another example where we have been misled by RCTs. Like CVD risk assessment, it is impossible to undertake a good long term RCT of high versus low SF consumption and CHD because there is so much crossover between study groups. Unfortunately many people (and some national societies) have misconstrued the inconsistent findings of the trials that have been done as showing either no relationship or a weak relationship rather than concluding that such trials are impossible to do well.
>>>>>>  
>>>>>> Beware the findings of theoretically ideal RCTs that are impossible to do well. High quality RCTs are great when they are possible but frequently misleading when they are not.
>>>>>>  
>>>>>> Regards Rod Jackson
>>>>>>  
>>>>>> Professor of Epidemiology
>>>>>> University of Auckland
>>>>>> New Zealand   
>>>>>>  
>>>>>>  
>>>>>> From: "Evidence based health (EBH)" <EVIDENCE-BASED-HEALTH@ JISCMAIL.AC.UK> on behalf of Juan Gérvas <[log in to unmask]>
>>>>>> 
>>>>>> Reply-To: Juan Gérvas <[log in to unmask]>
>>>>>> Date: Monday, 18 December 2017 at 10:46 AM
>>>>>> To: "Evidence based health (EBH)" <EVIDENCE-BASED-HEALTH@ JISCMAIL.AC.UK>
>>>>>> Subject: Re: new hypertension guidelines, controversy
>>>>>>  
>>>>>> John P. A. Ioannidis
>>>>>> Diagnosis and Treatment of Hypertension in the 2017 ACC/AHA Guidelines and in the Real World
>>>>>> https://jamanetwork.com/ jgournals/jama/fullarticle/ 2666624
>>>>>>  
>>>>>> A critic by Juan Gérvas (JG) @JuanGrvas and answers by John P. A. Ioannidis (JPAI) from 14th to 17th December 2017.
>>>>>>  
>>>>>> JG 1/ ignore the work done by the Cochrane (last published review 8t Aug 2017, SPRINT results included):
>>>>>> At the present time there is insufficient evidence to know whether a higher BP target (less than150 to 160/95 to 105 mmHg) or a lower BP target (less than 140/90 mmHg) is better for older adults with high BP.
>>>>>> http://www.cochrane.org/ CD011575/HTN_blood-pressure- targets-hypertension-older- adults
>>>>>>  
>>>>>> JPAI: I think my main point is entirely in line with the Cochrane review, I am questioning whether we can reap theoretical benefits in practice, even the title of my viewpoint implies this. A Viewpoint article is limited to 1300 words and 10 references, there is no way to cite everything.
>>>>>>  
>>>>>> JG. references should include the "key" references, and the Cochrane on is "the golden key". Cochrane' authors are very clear:
>>>>>> "There is insufficient evidence to know whether a higher BP target (less than150 to 160/95 to 105 mmHg) or a lower BP target (less than 140/90 mmHg)"
>>>>>>  
>>>>>> JPAI: "You did not cite Cochrane": I am one of the most fervent supporters of Cochrane worldwide, but I cannot agree to an almost religious imperative to must-cite Cochrane reviews as the "golden key".
>>>>>>  
>>>>>>  
>>>>>> JG 2/ ignore the social determinants; it is not "style of living" but "conditions of living"
>>>>>> Clinical decision rules relying on classic cardiovascular risk scoring could result in delayed drug therapy for patients with depression or low educational attainment or members of lower socioeconomic classes
>>>>>> http://www.sciencedirect.com/ science/article/pii/ S0091743511001599
>>>>>> https://academic.oup.com/ eurpub/article/15/5/441/526262
>>>>>>  
>>>>>> JPAI: the last paragraph of the viewpoint alludes to the “many high-risk patients remain undiagnosed even with very high blood pressure. Many others receive suboptimal treatment, even according to more conservative definitions of hypertension.” This includes the kind of patients that you mention.
>>>>>>  
>>>>>> JG: i agree. But it is very obscure. Why not to mention directly something like "Social determinants are absent in the new guidelines, as usual, but we need to go to the ‘causes of the causes" as poverty".
>>>>>>  
>>>>>> JPAI: I will continue telling people to exercise, if they can. I also see no diminution of dignity in telling people not to smoke. I wish I could solve poverty, but I can't. 
>>>>>>  
>>>>>>  
>>>>>> JG 3/ the rethoric of "shifting the health care system more toward prevention" has no scientific base, and may harm patients
>>>>>> A reconstituted National Health Service that prioritises prevention of sickness would fail all those who are ill now
>>>>>> http://www.bmj.com/content/ 334/7583/19
>>>>>> The concept of prevention: a good idea gone astray?.
>>>>>> http://equipocesca.org/en/the- concept-of-prevention-a-good- idea-gone-astray/
>>>>>>  
>>>>>> JPAI: same point as above, although we don’t fully agree here. I am one of the harshest critics of unnecessary, expensive prevention with all its labeling, overdiagnsosis and biases; but here we are talking about basic prevention, like smoking and exercise. If you think that eliminating smoking and encouraging people to exercise are not worthy goals, we disagree.
>>>>>>  
>>>>>> JG: in general, the health systems in developep countries are not yet even answering basic needs as helping patients to die with dignity, so we must be carefull when proposing more "prevention" because generally prevention means inequity because in many cases translate resources to "concern people": from patients to healthy, from poor to rich, form illiterate to universitary, from elderly to young (Iona Heath). Of course, i agree about smoking tobacco both in the consultation and in public health; about encouraging people to exercise, mainly in public health.. "Prevention is no always better than cure" http://equipocesca.org/is- clinical-prevention-better- than-cure/
>>>>>>  
>>>>>> JPAI: SPRINT has many problems (which I discuss), but it would be unfair to not recognize its effort and strengths. Even when I think that something is potentially horrible, my preference is to start by acknowledging its strengths (if any), because this establishes fairness. Then, list its problems, so as to let others conclude in what ways it is problematic rather than call it horrible. But this is a matter of style and we can certainly disagree on style.
>>>>>>  
>>>>>>  
>>>>>> JG 4/ ignore that tables of risk without impact analysis are useless
>>>>>> Translating clinical research into clinical practice: impact of using prediction rules to make decisions.
>>>>>> There is currently no evidence reported in these reviews that the prospective use of global cardiovascular risk assessment translates to reductions in CVD morbidity or mortality
>>>>>> https://www.ncbi.nlm.nih.gov/ pubmed/16461965
>>>>>> http://bmjopen.bmj.com/ content/7/3/e013650?rss=1
>>>>>>  
>>>>>> JPAI: I mention that “the risk estimator has also been criticized for lacking proper calibration and for overestimating risk, particularly in young individuals. This may lead more low-risk people to aggressive drug treatment with questionable benefit-to-harm ratios.” I have written a previous viewpoint in JAMA dedicated to the cholesterol guidelines that introduced this risk-approach and I think it does cover what you say in more detail: https://www.ncbi.nlm.nih.gov/ pubmed/24296612
>>>>>>  
>>>>>> JG: i agree. But the key point is that tables of cardiovascular risk lack impact analysis. So they are in fact "cristal balls".
>>>>>>  
>>>>>>  
>>>>>> JG 5/ ignore the low value of SPRINT results for people age 70 years and more
>>>>>> SPRINT, over age 70. The results are both unimpressive and of questionable significance.
>>>>>> https://www.curingmedicare. com/single-post/2015/11/12/ The-SPRINT-Blood-Pressure- Study-Small-Numbers- Questionable-Significance
>>>>>>  
>>>>>> JPAI: most of my Viewpoint is a pretty aggressive critique of SPRINT and its inappropriate translation to create these guidelines. I don’t think that the point that you raise, a subgroup analysis, is among the most important of SPRINT’s problems. If anything, the age subgroup analysis shows a trend for larger benefit in the elderly and the benefit expressed as absolute risk difference is >3-fold higher in the elderly than in younger patients. 
>>>>>> JG: this is personal appreciation but you viewpoint is a so soft critique of SPRINT that is sound like a prise. Verbattin: "SPRINT was a well-done study,.." 
>>>>>>  
>>>>>>  
>>>>>> 6/ did note mention that SPRINT included randomly assigned 9361 persons with a systolic blood pressure of 130 mm Hg or higher AND patients with an increased cardiovascular risk http://www.nejm.org/doi/full/ 10.1056/NEJMoa1511939#t= article Just only says: "SPRINT randomized 9361 patients with SBP greater than 130 mm Hg to intensive blood pressure control of SBP to less than 120 mm Hg vs less than 140 mm Hg" https://jamanetwork.com/ journals/jama/fullarticle/ 2666624
>>>>>>  
>>>>>> JPAI: I agree this could have been made clearer, although it is implicitly stated, e.g. in my third to last paragraph. At any rate, I thought you don’t believe risk calculations anyhow. 
>>>>>>  
>>>>>> JG: SPRINT has problems of internal and external validity, but in any case its results could be apply only to persons with a systolic blood pressure of 130 mm Hg or higher AND patients with an increased cardiovascular risk
>>>>>>  
>>>>>> 7/ ignore that lifestyle counselling might be good for your health...but has no impact on mortality
>>>>>> A community based, individually tailored intervention programme with screening for risk of ischaemic heart disease and repeated lifestyle intervention over five years had no effect on ischaemic heart disease, stroke, or mortality at the population level after 10 years.
>>>>>> http://www.bmj.com/content/ 348/bmj.g3617
>>>>>> Multiple risk factor interventions for primary prevention of coronary heart disease. The pooled effects suggest multiple risk factor intervention has no effect on mortality.
>>>>>> https://www.ncbi.nlm.nih.gov/ pubmed/10796813
>>>>>>  
>>>>>> JPAI: You cite the 2000 Cochrane review, while this has been updated several times since then. E.g. the 2011 update (https://www.ncbi.nlm.nih.gov/ pubmed/21249647) already shows clearly a mortality/clinical benefit for patients with hypertension (of relevance to what we are discussing) and diabetes: “Total mortality and combined fatal and non-fatal cardiovascular events showed benefits from intervention when confined to trials involving people with hypertension (16 trials) and diabetes (5 trials): OR 0.78 (95% CI 0.68 to 0.89) and OR 0.71 (95% CI 0.61 to 0.83), respectively.” For low-risk, general population people of course you will not see a clear benefit in mortality over modest follow-up, but are you arguing that anti-smoking efforts or telling people to exercise are unreasonable? If so, I respectfully disagree.
>>>>>>  
>>>>>> JG: The new hypertension guideline is for the general population, not for "patients with hypertension and diabetes" Cochrane 2011: "Interventions using counselling and education aimed at behaviour change do not reduce total or CHD mortality or clinical events in general populations but may be effective in reducing mortality in high-risk hypertensive and diabetic populations". By the way, hypertension defines according to previous definition, no the AHA/ACC new guideline.
>>>>>> Anti-smoking efforts are important in the public setting and in the clinical ones, but telling people to exercise in the clinical setting has very little impact/scientific base (grade C); see the USPSTF "The USPSTF recommends that primary care professionals individualize the decision to offer or refer adults without obesity who do not have hypertension, dyslipidemia, abnormal blood glucose levels, or diabetes to behavioral counseling to promote a healthful diet and physical activity. Existing evidence indicates a positive but small benefit of behavioral counseling for the prevention of CVD in this population. Persons who are interested and ready to make behavioral changes may be most likely to benefit from behavioral counseling. (C recommendation)" https://www.ncbi.nlm.nih.gov/ pubmed/28697260
>>>>>>  
>>>>>> and 8/ ignore that the AHA/ACC guideline wasn't based on a systematic evidence review
>>>>>> https://www.aafp.org/news/ health-of-the-public/ 20171212notendorseaha- accgdlne.html
>>>>>>  
>>>>>> JPAI: I kindly disagree, the report is a 481 page document that includes a systematic review and there is a separate publication of the systematic review published in multiple journals concurrently, e.g. https://www.ncbi.nlm.nih.gov/ pubmed/29133355
>>>>>>  
>>>>>> JG."The [AHA/ACC] guideline provided more than 100 recommendations, but a systematic review performed as part of the guideline's development considered only four key questions. Also, harms of treating a patient to a lower blood pressure were not assessed in the systematic review".
>>>>>>  
>>>>>> 2017-12-17 14:53 GMT+01:00 Anoop B <[log in to unmask]>:
>>>>>>> Interesting to note that that the guidelines did not review the quality of individual studies, risk of taking the medication, and how the SPRINT trial was heavily favored.  
>>>>>>>  
>>>>>>> Why don't you write a response to his letter Juan? 
>>>>>>>  
>>>>>>> Thank you juan for all your contribution here. 
>>>>>>>  
>>>>>>> On Sat, Dec 16, 2017 at 4:22 PM, Juan Gérvas <[log in to unmask]> wrote:
>>>>>>>> La American Academy of Family Physician (más de 115.900 miembros) ha decidido no aceptar la nueva guía de hipertensión propuesta por la American Heart Association y otras organizaciones profesionales.
>>>>>>>> The American Academy of Family Physicians (more than 115,900 members) has decided to not endorse the recent hypertension guideline from the American Heart Association, the American College of Cardiology and 9 other health professional organizations.
>>>>>>>> https://www.aafp.org/…/…/ 20171212notendorseaha- accgdlne.html
>>>>>>>> https://www.aafp.org/news/ health-of-the-public/ 20171212notendorseaha- accgdlne.html
>>>>>>>> 
>>>>>>>> -horrible paper by
>>>>>>>> John P. A. Ioannidis
>>>>>>>> Diagnosis and Treatment of Hypertension in the 2017 ACC/AHA Guidelines and in the Real World
>>>>>>>> https://jamanetwork.com/ journals/jama/fullarticle/ 2666624
>>>>>>>> -why is "horrible"? because
>>>>>>>> 1/ ignore the work done by the Cochrane (last published review 8t Aug 2017, SPRINT results included):
>>>>>>>> At the present time there is insufficient evidence to know whether a  higher BP target (less than150 to 160/95 to 105 mmHg) or a lower BP  target (less than 140/90 mmHg) is better for older adults with high BP.
>>>>>>>> http://www.cochrane.org/ CD011575/HTN_blood-pressure- targets-hypertension-older- adults
>>>>>>>> 2/ ignore the social determinants; it is not "style of living" but "conditions of living"
>>>>>>>> Clinical decision rules relying on classic cardiovascular risk scoring  could result in delayed drug therapy for patients with depression or low  educational attainment or members of lower socioeconomic classes
>>>>>>>> http://www.sciencedirect.com/ science/article/pii/ S0091743511001599
>>>>>>>> https://academic.oup.com/ eurpub/article/15/5/441/526262
>>>>>>>> 3/ the rethoric of "shifting the health care system more toward prevention" has no scientific base, and may harm patients
>>>>>>>> A reconstituted National Health Service that prioritises prevention of sickness would fail all those who are ill now
>>>>>>>> http://www.bmj.com/content/ 334/7583/19
>>>>>>>> The concept of prevention: a good idea gone astray?.
>>>>>>>> http://equipocesca.org/en/the- concept-of-prevention-a-good- idea-gone-astray/
>>>>>>>> 4/ ignore that tables of risk without impact analysis are useless
>>>>>>>> Translating clinical research into clinical practice: impact of using prediction rules to make decisions.
>>>>>>>> There is currently no evidence reported in these reviews that the prospective use of global cardiovascular risk assessment translates to reductions in CVD morbidity or mortality
>>>>>>>> https://www.ncbi.nlm.nih.gov/ pubmed/16461965
>>>>>>>> http://bmjopen.bmj.com/ content/7/3/e013650?rss=1
>>>>>>>> 5/ ignore the low value of SPRINT results for people age 70 years and more
>>>>>>>> SPRINT, over age 70. The results are both unimpressive and of questionable significance.
>>>>>>>> https://www.curingmedicare. com/single-post/2015/11/12/ The-SPRINT-Blood-Pressure- Study-Small-Numbers- Questionable-Significance
>>>>>>>> 6/ did note mention that SPRINT included randomly assigned 9361 persons with a systolic blood pressure of 130 mm Hg or higher AND patients with an increased cardiovascular risk http://www.nejm.org/doi/full/ 10.1056/NEJMoa1511939#t= article Just only says: "SPRINT randomized 9361 patients with SBP greater than 130 mm Hg to intensive blood pressure control of SBP to less than 120 mm Hg vs less than 140 mm Hg" https://jamanetwork.com/ journals/jama/fullarticle/ 2666624
>>>>>>>> 7/ ignore that lifestyle counselling might be good for your health...but has no impact on mortality
>>>>>>>> A community based, individually tailored intervention programme with screening for risk of ischaemic heart disease and repeated lifestyle intervention over five years had no effect on ischaemic heart disease, stroke, or mortality at the population level after 10 years.
>>>>>>>> http://www.bmj.com/content/ 348/bmj.g3617
>>>>>>>> Multiple risk factor interventions for primary prevention of coronary heart disease. The pooled effects suggest multiple risk factor intervention has no effect on mortality.
>>>>>>>> https://www.ncbi.nlm.nih.gov/ pubmed/10796813
>>>>>>>> and 8/ ignore that the AHA/ACC guideline  wasn't based on a systematic evidence review
>>>>>>>> https://www.aafp.org/news/ health-of-the-public/ 20171212notendorseaha- accgdlne.html
>>>>>>>> -un saludo juan gérvas @JuanGrvas 
>>>>>>>> 
>>>>>>>  
>>>>>>  
>>>>>  
>>>>>  
>>>>> 
>>>>  
>>>  
>> 
>> -- 
>> 
>> 
>> https://myownprivatemedicine.com/
>