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*The Spanish Association or Family Physians rejects the new hypertension ACC-AHA guideline.**La société espagnole des médecins de famille refuse les nouveaux seuils pour l'HTA prônée par la société américaines de cardiologie, y compris pour les sujets à risque élevé le suils reste à 140/90 (argumentaire en espagnol) * ¿Hipertensión? Mantenga la calma y los objetivos de siempre. No hay justificación para los cambios propuestos por el Colegio Americano y la Asociación Americana del Corazón (AHA/ACC) 2017. Crítica razonada de la @ *semfyc* <https://twitter.com/semfyc> https://www.semfyc.es/wp-content/uploads/2018/03/INFORME-guia-hta.pdf <https://t.co/H7MJHR3Et3> <https://t.co/H7MJHR3Et3> -un saludo juan gérvas @JuanGrvas 2018-01-31 19:22 GMT+01:00 Juan Gérvas <[log in to unmask]>: > Nueva guía hipertensión ACC-AHA: escasa en valorar beneficios/daños/costes/ > preferencias. > *Hypertension. New ACC-AHA: the guideline falls short in weighing the > potential benefits/harms, costs, and anticipated variation in individual > patient preferences.* > http://annals.org/aim/article-abstract/2670323/hypertension- > limbo-balancing-benefits-harms-patient-preferences-before-we-lower > -un saludo juan gérvas @JuanGrvas > > 2018-01-19 10:56 GMT+01:00 Juan Gérvas <[log in to unmask]>: > >> ¿Nueva guía para hipertensión? Reserve el bajar a 130/80 mm Hg para >> pacientes con algo riesgo. Los demás van bien con 140/90. Vía >> @sanoysalvoblog >> *While a blood-pressure treatment target of less than 130/80 mm Hg makes >> sense for high-risk patients, for everyone else it seems more reasonable to >> continue defining hypertension as a blood pressure of 140/90 mm Hg or >> higher.* >> >> *http://www.nejm.org/doi/full/10.1056/NEJMp1716193 >> <http://www.nejm.org/doi/full/10.1056/NEJMp1716193>* >> >> *-un saludo juan gérvas @JuanGrvas* >> >> 2017-12-23 1:16 GMT+01:00 Rod Jackson <[log in to unmask]>: >> >>> Hi Michael- these are good points and there clearly is uncertainty >>> around estimated CVD risk using various calculators and the estimated >>> benefit of treatment calculated by applying the RRRs from RCTs to these >>> risk estimates. >>> >>> However one of the many benefits of using a multi variable risk equation >>> to inform treatment decisions is that variability in any single risk >>> factor, like BP, has limited influence on the estimated risk. >>> >>> Moreover the benefit of treatment of say BP, is more closely related to >>> pretreatment predicted risk, than the pretreatment BP. >>> >>> Cheers Rod >>> >>> * * * * * * * * >>> sent from my phone >>> >>> >>> On 23/12/2017, at 09:44, Michael Power <[log in to unmask]> wrote: >>> >>> Hi Rod et al >>> >>> I have been following this conversation with interest, and would like to >>> widen the scope beyond decisions around hypertension and CVD to include >>> all health conditions. >>> >>> When making a decision, there are two kinds of information that I would >>> like to include in my options appraisal, but which have not been discussed: >>> what the stakes are, and what the uncertainties are. >>> >>> If it is a low stakes decision, e.g. whether to invest a few minutes to >>> find paracetamol for an inconvenient headache (or to throw the loose change >>> in my pocket away on a lottery ticket), it basically comes down to what I >>> find convenient or attractive. >>> >>> If it is a high stakes, imminent life or death situation, I would like >>> to know what the predictive interval is around the risk prediction so that >>> I know how seriously to plan for the worst outcome and how optimistically >>> to plan for the best outcome, >>> >>> The risk calculators and shared decision-making tools that I have seen >>> (from an experience that is way less than that provided by a systematic >>> review) ignore the uncertainties in predictions and do not help much in >>> taking account of the best and worst case scenarios in my decision-making. >>> >>> To bring the focus back to hypertension: what is the uncertainty around >>> the blood pressure estimate that is used in CVD risk calculators? My >>> personal experience is that there are some people whose blood pressure >>> fluctuates quite widely even when a white coat is out of sight and out of >>> mind. >>> >>> Michael >>> >>> >>> On 21 Dec 2017, at 21:56, Rod Jackson <[log in to unmask]> wrote: >>> >>> Hi Owen. Like James and Bill, I enjoyed reading your response and share >>> some of your concerns. I am particularly concerned about anti-democratic >>> decisions which is why I have spent the last 25 years developing guidelines >>> and conducting research aimed at facilitating a change from traditional >>> single risk factor based CVD risk management guidelines to multi variable >>> CVD risk prediction informed management guidelines. >>> >>> As I have mentioned in previous posts, you cannot make an informed >>> decision about lowering blood pressure (or LDL cholesterol etc) with >>> knowledge of the likely absolute risk associated with no intervention and >>> the absolute risk reduction associated with an intervention. Without this >>> information the management of CVD risk will always be un-democratic, >>> because individual risk factors are hopeless measures of absolute risk. >>> >>> I am in my early 60s and meet current US recommendations for statins, >>> based on my predicted 10-year CVD risk using the 2013 AHA/ACC Pooled Cohort >>> Equations. However a recommendation is a recommendation, not a rule, and as >>> the 2014 US high cholesterol guidelines first recommend assessing CVD risk, >>> I (and my general practitioner) am able to make an informed decision based >>> on the best estimates we have of risks and benefits. >>> >>> I have decided not to follow the US recommendations to start statins at >>> this stage for several reasons. First, I have used predicted CVD risk as >>> the starting point for estimating my risk. I then qualitatively >>> individualised this risk based on my clinical and epidemiological judgement >>> about the variables not included in the equation that are likely to >>> increase or decrease my personal risk. Based on this individualised risk, I >>> think my true risk is somewhat lower than the initial predicted risk, so I >>> am now on the borderline of the recommended treatment threshold. Second, >>> having estimated my risk without treatment (based on my qualitatively >>> individualised version of a quantitative predicted risk) I then applied >>> the relative risk reduction I could expect from statins (based on >>> meta-analyses of RCTs) to determine the likely absolute treatment benefit. >>> Informed by this estimated treatment benefit, I decided that the costs (to >>> a New Zealander the costs are mainly the hassle of taking drugs every day >>> because statins cost a few cents a day, plus the likelihood that I would >>> incorrectly blame the muscle aches I get anyway on statins) don’t currently >>> justify the benefits. I will probably change my mind sometime in the future >>> when the balance of risk, benefit and cost changes. >>> >>> Granted, I know more about CVD risk/benefit than most people, but most >>> of what I have described could be integrated into an electronic support >>> system. There are a number of rudimentary systems already and they will get >>> better with time. >>> >>> I consider this a more ‘democratic’ approach to CVD risk management than >>> previous approaches. It is not perfect but I am convinced it is a step in >>> the right direction. >>> >>> Or am I missing your point Owen? >>> >>> Cheers Rod >>> >>> On 22/12/2017, at 5:26 AM, McCormack, James <[log in to unmask]> >>> wrote: >>> >>> Hi Owen - thanks for your response - your ideas are definitely >>> interesting and I enjoyed your response but you haven’t answered what you >>> specifically would do for these people. The questions aren’t the results of >>> the logic of anticipatory care they are real life scenarios which require a >>> decision - and one option is doing nothing. I think Rod and I are VERY >>> aware of all the negative things that can happen when one treats risk >>> factors and for me it is why I have a huge problem with population >>> thresholds. >>> >>> Can I infer you believe one should never measure anyones blood pressure >>> and if blood pressure is measured it shouldn’t be treated regardless of the >>> number? >>> >>> Or would you do something differently than what I am describing for >>> these two scenarios? >>> >>> James >>> >>> >>> >>> On Dec 21, 2017, at 6:35 AM, Owen Dempsey <[log in to unmask]> wrote: >>> >>> Dear Rod and James, to paraphrase both of your questions: >>> >>> Your question Rod: >>> >>> *“Should we inform patients (or indeed their doctors) about their >>> predicted absolute CVD risk?”* >>> >>> And your question James: >>> >>> For a, “60 y/o male/female patient with no HX of CVD - otherwise >>> “normal” lipids and glucose non-smoker - family history is neither good nor >>> bad” with various BP measurements, 200/110, 145/95. You ask: >>> >>> *“What would you suggest be done?”* >>> >>> These questions are the result of 'the logic of (anticipatory) care' >>> where 'something must be done' because something has already been done >>> (Mol, 2006). But, I think these aren’t the right questions. >>> >>> What if we ask whether the CVD risk assessment should have been done at >>> all? >>> >>> What if we ask: >>> >>> "What are the overall impacts of anticipatory care such as CVD risk >>> assessments for the asymptomatic (footnote 1)?" >>> >>> I outline seven consequences. >>> >>> 1. *A label* >>> >>> First, a CVD risk screening provides a statistical probablity of risk >>> that is presented to a particular prospective patient. >>> >>> 2.* Loss of individuality* >>> >>> Second, the presentation of the risk is received as an ‘unconditional >>> demand’ (no matter who ‘you’ are in your uniqueness as a human being, this >>> ‘is’ your risk, your responsibility, which you shall be motivated to >>> reduce, and there is treatment for it). In this way ‘a’ particular >>> prospective patient is transformed into ‘the’ universal patient (for a good >>> summary see Vanheule, 2002). >>> >>> 3. *Exploitation of desire* >>> >>> Third, the risk statistic inevitably provokes a feeling of avoidable >>> mortality, and fear is incited. The demand to take responsibility, >>> alongside the feeling of precarity, incites a desire to take advantage of >>> the promise of prevention. Because desire is inflicted through demand and >>> fear the offer, in effect, coerces compliance. Thus, all in all, screening >>> exploits the desire it incites through our need to feel adequate to the >>> demand perceived. >>> >>> 4. *Agency but at a price* >>> >>> Fourth, true, some may reject this particular demand to be ‘the’ >>> patient, and refuse to be recruited, but this may be accompanied by loss of >>> trust in the practitioners, confusion, anxiety, guilt, and stress (for an >>> insightful interview with two patients listen to The Today Programme, 2012). >>> >>> 5.* An Anti-democratic decision* >>> >>> Fifth (a key point), the decision making is not democratic for three >>> reasons: a) the inevitable power imbalance, which can’t be helped, b) the >>> way the perceived demand coerces compliance, and c) because it is >>> impossible for ‘a’ patient to value the high probablity of over-treatment >>> as a harm as such. No individual can ever say: ‘Oh, this is what >>> over-treatment (or over-diagnosis) feels like.’ And, if a harm can’t be >>> imagined it can’t be adequately valued as a harm. And because over >>> diagnosis is un-valueable, a) it is not taken into account by policymakers >>> when deciding whether such care is a good thing', and b) it maybe ignored >>> by patients or may creates confusion, distrust and a loss of feeling >>> cared-for. >>> >>> 6. *Destruction of loving care* >>> >>> Sixth, the transformation of ‘a’ particular patient into ‘the’ universal >>> patient, not only creates a feeling of inadequacy (as described above), it >>> also transforms the caregiving relationship into a mechanical transaction >>> without compassion(Vanheule, 2002). It destroys love in the caregiving >>> relation. >>> >>> 7. *Suffering is sacrificed* >>> >>> Seventh, three forms of opportunity cost are incurred: a) the expansion >>> of this type of care costs money that can’t be spent on care to relieve >>> suffering (McCabe et al, 2008; Garner and Littlejohns, 2011; Dillon, 2015), >>> b) the expansion of new forms of anticipatory care, such as genetic >>> profiling, reduces the cost effectivness of health services (footnote 2), >>> and c) the practitioners time spent on anticipatory care is time taken away >>> from relieving suffering (Vanheule, 2001). >>> >>> *Conclusion* >>> >>> The market driven 'system' will continue to expand this mode of care >>> regardless of the consequences. Simply put, caregivers and practitioners >>> are incited to try to do too much. >>> >>> Although the the consultation is always anti-democratic because of the >>> power held by the caregiver, anticipatory care is *both* >>> anti-democratic *and* destructive of lives and care. >>> >>> Therefore individual practitioners should confront and refuse to >>> implement anticipatory care which is a destructive form of oppression. >>> >>> Owen >>> >>> *references* >>> >>> Mol, A. (2006) *The Logic of Care - Health and the Problem of Patient >>> Choice*. Abingdon: Rutledge. >>> >>> Dillon, A. (2015) Carrying NICE over the threshold, https://www.nice.or >>> g.uk/news/blog/carrying-nice-over-the-threshold. >>> >>> Garner, S. & Littlejohns, P. (2011) Disinvestment from low value >>> clinical interventions: NICEly done? *BMJ*, 343. >>> >>> McCabe, C., Claxton, K., & Culyer, A. (2008) The NICE Cost-Effectiveness >>> Threshold: What it is and What that Means. *IDEAS Working Paper Series >>> from RePEc*. >>> >>> The Today Programme (2012) I was railroaded into cancer surgery, London >>> BBC radio 4 >>> >>> Vanheule, S. (2001) Burnout and Psychoanalysis: A Freudo-Lacanian Point >>> of View. *Journal for the Psychoanalysis of Culture and Society, 6(2), >>> 2001, pp.265-271*, 6(2): 7. >>> >>> Vanheule, S. (2002) Caring and its Impossibilities: A Lacanian >>> Perspective. *Organizational and Social Dynamics*, 2(2): 21. >>> >>> Wakefield, J. (2016) Diagnostic Issues and Controversies in DSM-5: >>> Return of the False Positives Problem. *Annu. Rev. Clin. Psychol.*, 12: >>> 28. >>> >>> ------------------------------ >>> >>> 1. Anticipatory care, anti- in advance, cipere- to take in hand, >>> consists of care of asymptomatic individuals, that predicts and determines >>> future health states as pathological and also determines the action that >>> msut be taken to prevent those states. It includes, for example, evoking >>> symptoms, cancer screening, risk stratification, and innovative diagnostic >>> labelling (Wakefield, 2016). >>> >>> 2. See: https://myownprivatemedicine.com/2017/09/26/the-anticipatory >>> -care-paradox-and-overdiagnosis-subjective-pragmaticism-trum >>> ps-objective-empiricism/ >>> >>> >>> >>> >>> >>> >>> >>> On Wed, Dec 20, 2017 at 10:39 PM, Rod Jackson <[log in to unmask] >>> > wrote: >>> >>>> Hi Juan – I have to challenge your statement that the new 2017 ACC/AHA >>>> High Blood Pressure Guidelines are bizarre. I think that is probably a fair >>>> description of the previous US guidelines which recommended treating low >>>> risk younger people while not treating higher risk older people and was >>>> mainly based on blood pressure thresholds. >>>> >>>> >>>> >>>> I also have to admit to finding your statement: ‘i do not agree that >>>> risk estimates should be made to help inform patient choice’ somewhat >>>> bizarre. >>>> >>>> >>>> >>>> Measuring someone’s blood pressure is measuring their CVD risk. It is >>>> just an extremely poor measure of absolute risk and therefore an extremely >>>> poor indicator of absolute treatment benefit. Can I ask you, are you >>>> inferring that you would never measure blood pressure or tell someone what >>>> their blood pressure is? >>>> >>>> >>>> >>>> Unfortunately, I think your interpretation of what is good evidence is >>>> too rigid and too simplistic. There are no perfect RCTs and we always have >>>> to do our best to integrate the totality of evidence. Evidence hierarchies >>>> are simply guides not rules and should not be applied too literally. You >>>> also do not appear to have acknowledged that the evidence you appear to >>>> expect (a large high quality long term RCT randomising people to a risk >>>> prediction-based strategy versus a risk factor-based strategy with CVD >>>> events as the outcome) is an impossibility, as reflected in the multiple >>>> failed attempts to do this. >>>> >>>> >>>> >>>> While the 2017 ACC/AHA Guidelines on High Blood Pressure are nowhere >>>> near perfect, at least by by explicitly including a risk prediction step, >>>> they are moving in the right direction. James has clearly articulated the >>>> importance of informed shared decision making and neither clinicians nor >>>> patients can take part in an informed decision about CVD risk management >>>> without having an estimate of patients’ CVD risk. >>>> >>>> >>>> >>>> I agree that in their current form the new Guidelines are likely to >>>> lead to a significant increase in treatment, but whether this represents >>>> overtreatment depends on what one considers ‘ideal treatment,’ which will >>>> differ from person to person. At least by recommending use of a >>>> quantitative risk assessment for some patients, an informed discussion >>>> about risks and benefits is possible. Treatment recommendations based on a >>>> blood pressure level alone precludes any meaningfully informed decision by >>>> either the doctor or the patient. >>>> >>>> >>>> >>>> Best wishes and Merry Christmas. >>>> >>>> >>>> >>>> Rod Jackson >>>> >>>> CVD epidemiologist >>>> >>>> University of Auckland, New Zealand >>>> >>>> >>>> >>>> >>>> >>>> >>>> >>>> >>>> >>>> *From: *"Evidence based health (EBH)" <EVIDENCE-BASED-HEALTH@JISCMAI >>>> L.AC.UK> on behalf of Juan Gérvas <[log in to unmask]> >>>> *Reply-To: *Juan Gérvas <[log in to unmask]> >>>> *Date: *Wednesday, 20 December 2017 at 10:18 PM >>>> >>>> *To: *"Evidence based health (EBH)" <EVIDENCE-BASED-HEALTH@JISCMAI >>>> L.AC.UK> >>>> *Subject: *Re: new hypertension guidelines, controversy >>>> >>>> >>>> >>>> -no, James, i do not agree that risk estimates should be made to help >>>> inform patient choice >>>> >>>> -this estimation has no predictive value and cannot guide any decision >>>> >>>> -it is like helping patients with a cristal ball in astrology >>>> >>>> -the new bizarre *2017 ACC/AHA Guidelines *for hypertencion increase >>>> the number of people harm without benefits >>>> >>>> There is currently no evidence 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 >>>> >>>> >>>> <http://bmjopen.bmj.com/content/7/3/e013650?rss=1> >>>> >>>> >>>> <http://bmjopen.bmj.com/content/7/3/e013650?rss=1> >>>> >>>> >>>> <http://bmjopen.bmj.com/content/7/3/e013650?rss=1> >>>> >>>> >>>> <http://bmjopen.bmj.com/content/7/3/e013650?rss=1> >>>> >>>> >>>> >>>> 2017-12-20 8:32 GMT+01:00 McCormack, James <[log in to unmask]>: >>>> >>>> Hi Owen - I’m also confused - as Rod says, a patient scenario would be >>>> very useful - may I suggest 2 different ones. >>>> >>>> >>>> >>>> 1) A 60 y/o male/female patient with no HX of CVD - otherwise “normal” >>>> lipids and glucose non-smoker - family history is neither good nor bad >>>> >>>> Blood pressure is 200/110mmHg - properly measured on many occasions >>>> over a number of weeks or months - non-drug measures haven’t worked etc - >>>> no symptoms of end-organ damage >>>> >>>> >>>> >>>> 2) A similar patient but in this case the blood pressure is 145/95 mmHg >>>> - again measured appropriately etc >>>> >>>> >>>> >>>> My question would be, what would you suggest be done for these two >>>> individuals to deal with the anticipatory care issue you are describing. >>>> >>>> >>>> >>>> Hope this makes sense. >>>> >>>> >>>> >>>> James >>>> >>>> >>>> >>>> >>>> >>>> >>>> >>>> On Dec 19, 2017, at 11:10 PM, Rod Jackson <[log in to unmask]> >>>> wrote: >>>> >>>> >>>> >>>> Hi Owen. I have read your two recent posts several times and >>>> unfortunately I don’t understand what you are trying to say. >>>> >>>> >>>> >>>> Would you mind explaining your key points using a patient scenario. >>>> >>>> >>>> >>>> Are you suggesting that we shouldn’t inform patients (or indeed their >>>> doctors) about their predicted absolute CVD risk and our best estimate of >>>> the likely absolute treatment benefit? Or are you suggesting the opposite? >>>> >>>> >>>> >>>> Unless one predicts the patient’s absolute risk, it is impossible to >>>> determine the likely absolute treatment benefit. As you know the >>>> traditional practice of making treatment decisions on blood pressure alone >>>> is also a decision based on estimated risk and benefit (albeit relative >>>> risk and relative benefit which are not clinically meaningful). >>>> >>>> >>>> >>>> Regards Rod Jackson >>>> >>>> >>>> >>>> >>>> >>>> *From: *"Evidence based health (EBH)" <EVIDENCE-BASED-HEALTH@JISCMAI >>>> L.AC.UK> on behalf of Owen Dempsey <[log in to unmask]> >>>> *Reply-To: *Owen Dempsey <[log in to unmask]> >>>> *Date: *Wednesday, 20 December 2017 at 2:49 AM >>>> *To: *"Evidence based health (EBH)" <EVIDENCE-BASED-HEALTH@JISCMAI >>>> L.AC.UK> >>>> *Subject: *Re: new hypertension guidelines, controversy >>>> >>>> >>>> >>>> Dear all, >>>> >>>> I'm responding to further my argument that anticipatory care is >>>> anti-democratic, and to respond to James’ comments about: ‘much of health >>>> being about managing expectations’ etc.. >>>> >>>> James, you introduced a few concepts along the way so I apologise for >>>> the length of this post. To avoid us talking past each other I try to >>>> clarify some points. >>>> >>>> First, consider a) *health* and b) *anticipatory care*. >>>> >>>> First, health: for me, as a clinician, is about maximising an >>>> individual’s personal capacity to adjust to life’s slings and arrows, >>>> ageing etc, and not, as the WHO might have it, an aspiration of wellbeing >>>> etc to be achieved by care. My view on this follows Canguilhem’s (the >>>> French Philosopher of Medicine) conceptions of health and disease (Horton, >>>> 1995). Health care, for me is about relieving suffering and being very >>>> careful not to injure the individual human's delicate ecosystem with >>>> injudicious, hopeful interference, in order to prolong life. >>>> >>>> And, second, for me the discussion here is about what I call >>>> anticipatory care, I define this as care applied to asymptomatic >>>> individuals with tests or diagnoses that determine predicted future states >>>> as pathological, and for which preventive action is specified. Anti - in >>>> advance; cipere – to take in hand. >>>> >>>> *'expectations'* >>>> >>>> I agree that ‘managing expectations’ and ‘correcting’ misguided >>>> ‘assumptions’ is an important part of a clinician’s role. However managing >>>> expectations is necessary because expectations are actually being created, >>>> and these prey on people's fear and exploit desire. Some, as you say, >>>> ’don’t want to be told what to do’ - I agree, they may walk away, or not >>>> uncommonly in my experience, end up confused, or even distressed and >>>> railroaded into care (The Today Programme, 2012). One way to 'manage' this >>>> would be to avoid creating the expectations in the first place by refusing >>>> to offer this kind of care. >>>> >>>> *'the only way'* >>>> >>>> You say ‘the only way’ is to have an ‘open discussion’. However, this >>>> already assumes that these forms of care are ‘a good thing’ to offer, and >>>> so a discussion has already been enforced. Another way might be to follow >>>> the Amercian famiily physicians and refuse to follow harmful guidelines in >>>> the first place. >>>> >>>> *'the issue' * >>>> >>>> You also say ‘the issue is that the magnitude of the benefit vs the >>>> side effects, cost and inconvenience re often of similar magnitude’. But I >>>> would argue that ‘the issue’ at stake here is broader than this. Thus, >>>> anticipatory care often comes with professional guidelines that determine >>>> clinical practice, recruiting practitioners to harmful practices, and these >>>> forms of care cause opportunity costs elsewhere. The market dictates what >>>> shall become standard of care, and NICE for example routinely sanctions >>>> care that is less cost effective than care that will be discontinued to >>>> afford the ‘new model’. >>>> >>>> For example, a very expensive new genetic prediction test for cancer >>>> recurrence may, for example, cause cost saving cuts elsewhere in the >>>> publicly funded service and indirectly, lead to withdrawal of, for example, >>>> mental health services for young people with depression (McCabe et al, >>>> 2008). Expensive anticipatory care, of dubious value, also bankrupts >>>> individuals prey to fear, the private health care sector and insurance >>>> companies (Baum, 2015, personal communication, article available on >>>> request). >>>> >>>> The anticipatory care paradox by which expanding care destroys care and >>>> lives is what I call neoliberalism's ‘Perverse Care Law’. >>>> >>>> *'open discussion about … harms'* >>>> >>>> Harms such as over-diagnosis are never personally actually experienced >>>> as such. This means, I think, that it is impossible for a prospective >>>> patient to imagine over diagnosis as a harm as such, and to take it into >>>> account when a decision is being enforced. What some patients may be >>>> valuing instead, in the light of their knowledge about over-diagnosis, is a >>>> lack of their trust in the profession’s offer of care. >>>> >>>> *‘everybody has different values and prejudices’* >>>> >>>> Yes – but each person is also vulnerable to the way care can act as a >>>> commodity ‘promising the potential to prolong life’ in ways that exploit >>>> desire. There is a contradiction, perhaps even an irony here, in the way >>>> health care science make such profound assumptions about the human >>>> condition and at the same time silences any commentary on the essential >>>> features of that condition as always prone to desire and fantasy, by >>>> calling such commentary unscientific. >>>> >>>> I think that professional caregivers have a role to protect lay people >>>> from having their desires exploited. >>>> >>>> So I would stand by my view that anticipatory care under neoliberalism >>>> is anti-democratic, it: a) exploits desire, b) coerces compliance, c) >>>> causes distress, d) bankrupts and e) destroys health and care for many. It >>>> should be distrusted, first and foremost by professional caregivers. >>>> >>>> >>>> >>>> Owen >>>> >>>> Owen Dempsey >>>> >>>> >>>> >>>> >>>> >>>> >>>> >>>> Baum, M. (2015) Oncotype Dx Use in Node-Negative Luminal A Breast >>>> Cancer Adds Only Cost >>>> >>>> Horton, R. (1995) Georges Canguilhem: philosopher of disease. >>>> >>>> *J R Soc Med *88: 4. >>>> >>>> McCabe, C., Claxton, K., & Culyer, A. (2008) The NICE >>>> Cost-Effectiveness Threshold: What it is and What that Means. *IDEAS >>>> Working Paper Series from RePEc*. >>>> >>>> The Today Programme (2012) I was railroaded into cancer surgery, London >>>> BBC radio 4 >>>> >>>> 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, Dec 19, 2017 at 12:37 PM, Mohammed T. Ansari < >>>> [log in to unmask]> wrote: >>>> >>>> Interesting discussion. Just adding my two cents on impact. >>>> >>>> >>>> >>>> Impact of guidelines is not practically possible to estimate without >>>> first implementing the guidelines -- whether guidelines of therapy or risk >>>> prediction/diagnostic testing guided therapy. Impact assessment is a >>>> post-guideline implementation step. >>>> >>>> >>>> >>>> Please see this Knowledge-to-Action Framework: Straus SE, Tetroe J, >>>> Graham I: Defining knowledge translation. CMAJ. 2009, 181: 165-168. >>>> >>>> >>>> >>>> On Tue, Dec 19, 2017 at 6:57 AM, Juan Gérvas <[log in to unmask]> >>>> wrote: >>>> >>>> -thanks for the information and suggestions >>>> >>>> -your guide, James, is an excellent one, no doubt “Simplified Lipid >>>> Guidelines” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4607330/ >>>> >>>> -but you have covered just one step in the development of a clinical >>>> prediction rule (risk table, etc) >>>> >>>> -there are three: >>>> *(1) development of the prediction rule; (2) external validation of >>>> the prediction rule (‘‘validation’’), that is, testing the rule’s accuracy >>>> and thus generalizability in data that was not used for the development of >>>> the rule, and subsequent updating if validity is disappointing; and (3) >>>> studying the clinical impact of a rule on physician’s behavior and patient >>>> outcome* >>>> *https://www.ncbi.nlm.nih.gov/pubmed/19208371 >>>> <https://www.ncbi.nlm.nih.gov/pubmed/19208371>* >>>> >>>> -this is exactly the problem with the *2017 ACC/AHA Guidelines *and my >>>> critic to John Ioannidis for not signaling it in his Viewpoint in JAMA >>>> >>>> -we cannot accept this guideline (and transform almost half of the >>>> Humanity in "siskness persons") without having validation (accuracy) and >>>> formal impact analysis >>>> >>>> -un saludo juan gérvas @JuanGrvas >>>> >>>> >>>> >>>> 2017-12-19 11:41 GMT+01:00 Dr Geoff Schrecker < >>>> [log in to unmask]>: >>>> >>>> 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)" <EVIDENCE-BASED-HEALTH@JISCMAI >>>> L.AC.UK> 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)" <EVIDENCE-BASED-HEALTH@JISCMAI >>>> L.AC.UK> >>>> >>> 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 <http://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@ JISCMA >>>> IL.AC.UK <http://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.n >>>> cbi.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/ >>>> > >>>> >>>> >>>> >>>> >>>> >>>> >>>> >>>> >>>> >>>> -- >>>> >>>> >>>> >>>> >>>> >>>> https://myownprivatemedicine.com/ >>>> >>>> >>>> >>>> >>>> >>> >>> >>> >>> -- >>> >>> >>> https://myownprivatemedicine.com/ >>> >>> >>> >>> >> >