New Blood Pressure & Cholesterol Guidelines - Edited*

Alarming!

by Repero - 2024-07-22 06:15:27

So all that precribing of tons of BP and statin meds over decades is totally without benefit?

Penguin

by piglet22 - 2024-07-22 06:20:38

Had a quick look at NNT.

Quite an impressive list of contributors who should know what they are talking about.

What we should draw from this and it's need in the first place, is the sheer complexity of modern medicine.

Compared to centuries ago, we are now spoiled for choice when it comes to drugs and treatments.

Thank goodness the days of blood-letting and highly toxic formulations are gone, but now we and the clinicians are faced with a new set of problems, to treat or not to treat, introducing new undesirable side effects.

Many of us already know what a juggling act it is. The Ramipril cough, the diuretics’ need to pee, the high dose of beta-blockers to defeat the ectopics and the fatigue that follows.

That's just the tip of the iceberg.

If I miss one dose of medication - four for hypertension alone - my BP shoots up. Immediately you enter the risk zone. That's just one instance where the benefits outweigh the real and serious risks.

Thank goodness we have a choice and that people in the background are keeping a watchful eye on things.

We have NICE (National Institute for Clinical Excellence), but with a dose of UK healthy scepticism, this is a lot to do with the bottom line.

Risk calculator

by Repero - 2024-07-22 06:50:02

It is interesting to play around with the UK coronary risk calculator Qrisk3 - https://www.qrisk.org/index.php

This calculates the 10 year risk of heart attack and stroke based on your personally declared patient data - including whether or not you take BP meds. The results must be statistically based, i.e. it tells you what percentage of the national population with the same patient profile as yourself actually suffered heart attack or stroke. This implies that evidence of the real clinical effect of BP meds is contained within the national data.

As an experiment, I declared that I did not take BP meds, and had a systolic pressure of 135 mmhg: Qrisk3 told me that I have a 10 year risk of heart attack or stroke of 25.3%.

I then said that I did take the meds, and had a reduced systolic pressure of 125 mmhg: the predicted risk rose slightly to 25.6%. In other words, the medication had not reduced my risk of serious disease.

Does anyone read this differently?

Risk calculator PLUS

by Repero - 2024-07-22 07:13:47

Further to my last.

If, using Qrisk3, I declare that my systolic BP is 125, but that I did not take meds to achieve this, my risk reduces from 25.3% to 24%.

This indicates that lower BP is a good thing, but not if it is achieved by taking meds.

Mild hypertension increases risk of stroke

by crustyg - 2024-07-22 07:16:20

A large study in the 1980s looked at treatment of hypertension as a way to avoid death from cardiac causes: it wasn't very good as a way of avoiding a cardiac death.  The big surprise was the effect of treating mild hypertension on stroke rates.  [Edited] This level of hypertension is not to be confused with malignant hypertension - 50% survival less than 12months, mostly from cardiac causes.

Around the 1990s there was a big debate about the role of dietary sodium in high BP.  Turns out that it matters a lot.

So if you want to live a more healthy life with fewer avoidable issues, reduce your BP: either by reducing dietary sodium + taking more exercise + losing weight to ideal + reducing alcohol intake, OR by taking medication.  Your choice.  Ideal BP - the lowest that you can manage without feeling faint when standing from seated for some time.  If 120/70 is good, 115/60 is better.  And, I suspect, 110/55 better still, as long as I don't feel faint at the top of the stairs.  And, no, I'm nowhere near there, sadly.

Crustyg

by Repero - 2024-07-22 07:52:05

Could you kindly expand on your comment "The big surprise was the effect of treating mild hypertension on stroke rates.  Not to be confused with malignant hypertension - 50% survival less than 12months."

I didn't quite get this. Sorry.

Website

by Penguin - 2024-07-22 08:27:26

Piglet, yes there are some impressive contributors.  The way in which information - risks / benefits - are presented to us (usually) was most interesting to me. I liked that this website gives you a traffic light system and gives you the information in a way which allows you to see the effects clearly e.g. this is what the drug says it will do and this is how many people benefitted in that regard during trials.  If you know that say, only 1 person benefitted and many more suffered from the side effects that you have been told are 'rare' then you can evaluate more usefully whether or not the drug is for you. 

I should say that evaluating any decision with your doctor is always recommended - but you all know that. 

Repero - I'll let Crusty answer your questions......

....and btw I'm not saying that the drugs are no good, or not fit for purpose, I'm saying that this is a useful tool for cutting through the manner in which someone else (with or without a commercial interest) may have interpreted the data and presented it to you.    

We all need to know where we stand so that we can make informed choices and people like you and me can't do this when presented with complex trial data.  The NNT gives you figures that most people can understand better. 

I was a bit concerned about the amount of people who developed diabetes on statins.  Is that because a statin provides the green light to continue with poor lifestyle choices do you think? It's not unknown!

It's important to remember what each category is looking into as well e.g. there was more evidence for positive results from statins in people with heart disease than in those without.  Two different results. 

Repero

by piglet22 - 2024-07-22 08:42:40

I wouldn't read anything into the difference between 25.3% and 24%. Too close to call and probably the error bars are more than the difference.

It always amuses me when I fill the washing machine. No matter how much wet washing or how wet, it always says 44% moisture.

Do I trust it, of course not. But it churns out a number.

One decimal place can throw you into being declared type 2 diabetic or one integer makes you a heavy drinker. Or your BMI is too high.

The surgery stuck my Qrisk3 figure onto my record, no notification, no explanation, no change of advice. And that's where it will remain.

A dilemma

by Gemita - 2024-07-22 09:19:35

A timely post Penguin, thank you.  

In an acute situation, of course meds are needed to bring down dangerously high blood pressure or heart rates.  High blood pressure/heart rates over time as we all know is very dangerous and can lead to heart attacks, strokes, heart failure, kidney disease, arterial disease, vascular dementia and many other diseases including eye disease.

The problem comes when these patients are put on high dose meds and are not followed up or reviewed regularly and they start to experience unwanted side effects, perhaps leading to weakness and falls.  Some side effects of meds may cause significant injury, particularly in the elderly who are often very frail and already have balance problems at the start of treatment.

Multiple meds can be dangerous and require close monitoring to be safe especially in the elderly when a compromise often has to be reached between acceptable risks versus benefits.  In the elderly doctors should perhaps never expect perfect blood pressure results.  For example, for over-80s because it is normal for arteries to get stiffer with ageing, the ideal blood pressure might be acceptable at around 145/90 (according to our GP) which is clearly not an ideal blood pressure reading.  We have to treat the patient based on their individual health conditions, symptoms and tolerance to take multiple meds, not always on their blood pressure numbers.  

As we know, taking a pill is the easy way out, but it is not always the answer to treat a health condition.  It is far better to change our ways (through diet, lifestyle etc.) to prevent disease, whenever possible, or to use meds for short periods only to treat any acute symptoms.  

I will certainly not take a new medication without it being absolutely necessary.  For example I know I need my anticoagulant to prevent/protect me from an AF related stroke but it is less clear whether I will need a Statin to bring down my cholesterol levels which are only borderline high (probably due to natural loss of oestrogen and being female) before I have tried other more natural means like exercise and diet. 

Next Monday I will have my angiogram Penguin, so I will know whether I have coronary artery disease or micro vascular disease.  Not looking forward to it.  Perhaps I will be able to make an “informed” decision then, but I will not be pushed into making any decisions about lifelong meds that may or may not make a difference.

Gemita

by Penguin - 2024-07-22 09:34:00

I recommend 'A Statin Free Life' by Dr Aseem Malhotra, who is a London based cardiologist and whose father was heavily involved with the BMA. He is an advocate for good advice, simply and clearly put to the patient. I found the book informative. 

The NNT is an initiative explained in the book. 

Good luck with your angiogram tomorrow.  

Repero

by Penguin - 2024-07-22 10:15:19

Re: QRISK 3 calculator. 

I haven't checked this, but was told that 'age' is one of the variables that may have considerable weight attached to it. E.g. Once you get over 60 years of age the weighting attached to age may tip you into the 'at risk' category and it may prove difficult to stay below the 10% result that is thought to be desirable.

The weighting of variables and how that is worked out is beyond me, but worth a try perhaps?

My own risk came out pretty well - because my BMI is OK and my BP is usually low-normal. Age and cholesterol are my irritants although I'm no longer convinced that there is any benefit to lowering cholesterol whatsoever and wonder why on earth I've been bothering! 

Risk and unexpected findings

by crustyg - 2024-07-22 11:13:20

Penguin: I saw my first Familial Hypercholesterolaemia (FH) patient shortly after qualification in 1980: heart attack playing Sunday AM football, aged 28.  Would have been a heterozygous (one duff gene) for FH - two duff genes and probably wouldn't have survived to 20. Massively high cholesterol levels: AFAIK no-one has ever been able to show a 'safe' level for LDL-chol - higher means higher risk.  But at what level does the cost/benefit analysis cease to be worth it?  And cost here isn't just drug costs.

BP is much the same: lower is better, down to the point of feeling faint on standing, and higher means higher risk of stroke.

Thinking we know stuff and then finding from a properly run study that we don't is the discipline that keeps good docs humble.  Statins weren't the first attempt to control cholesterol production and no-one running the 'treating hypertension might save cardiac deaths' study expected such a big difference in stroke rates between treated and untreated.

Always worth remembering that the patients on a well known spreadable margarine had more cardiac problems in the first trial than those eating butter, and that the HIV-patients on the first treatment died more quickly than the controls.

There really are no 'Nevers' or 'Always' in medicine.  Life just isn't like that.

In the unlikely event of my reaching the grand age of 90 (in our household, that's called A Survivor), I'm sure that the risk calculators will show a >25% chance of death within a year for me.  We all know that we're going to die: what interests most of us is quality of life before that time, and please don't tell me the hour and manner of my passing.  I really don't want to know in advance.  Some are not that lucky, e.g. Robin Williams.

Thanks everyone

by Repero - 2024-07-22 11:19:05

Thank you for an interesting discussion, which has wandered a little.

The original point raised by Penguin's NNT articles is that statistical data show that these meds do much more harm than they do good.

The Qrisk3 calculator seems to confirm the lack of benefits.

Why are they still routinely prescribed?

Your Perspectives - Crusty & Repero

by Penguin - 2024-07-22 12:55:55

Thank you for sharing. 

Crusty - I read a book by Dr Malcolm Kendrick 'Statin Nation'.  I didn't understand a lot of it as it was over my head, but FH was one of the topics and he had some interesting things to say. If you ever read it, let me know what you think.  

Repero - You say 'The original point raised by Penguin's NNT articles is that statistical data show that these meds do much more harm than they do good'.  

Er, No! That wasn't the point. Excuse me for being more specific than your statement allows, Repero. 

 The point was that if you take a BP med and your BP is mildly elevated it seems that the drug may have no effect on the clinical endpoints which the drug aims to treat and you may suffer side effects. 

Of course, there will be a different set of results for people with more elevated BP and I haven't looked at those.  I was interested in the people who fall into the revised, lower banding.

The point was that the guidelines now suggest that BP is elevated at much lower figures than before and this may mean that people with BP at these mildly hypertensive levels may need to determine whether or not to accept prescribed drugs to lower their BP.  The NNT provides them with information which may help them arrive at a decision which they and their doctors feel comfortable with.  

Similarly, statins undeniably lower cholesterol.  The risks of cholesterol are still up for debate it seems and it is an ongoing area for controversy.  Again, the NNT tries to help patients decide whether or not a statin will help them or not by providing statistics which suggest what effect on specific clinical outcomes may be expected from taking / not taking a statin.  The articles have different results depending upon whether or not the recipient has been diagnosed with cardio vascular disease.  

Let's not put words in one anothers' mouths here Repero.  

'Why are they still routinely prescribed?' you ask. Good question!  Perhaps statistics and the way that they are presented can be hugely influential.  That's why it's important to ensure that the statistics are presented in a way that is helpful to all, and that is why I introduced the NNT database to forum members.

As always, it is a matter for personal choice and discussions with your clinicians are probably very wise before making any decisions.  They are the prescribers afterall and you should be asking them your question, rather than asking me perhaps. 

Penguin

by Repero - 2024-07-22 13:48:28

I stand chided.

I really had no intention of putting words in your mouth Penguin. I just meant that it was you who introduced us to these articles. My one-line summary was my own, I wasn't ascribing it to you.

That now looks to be a bit over dramatic and based on a partial reading. I guess I got carried away when I read, concerning statins for those with no known heart disease, that no lives were saved, less than 1% were saved from a heart attack and 0.7% saved from a stroke, against 2% who became diabetic and 10% who suffered muscle damage. The authors further suspect that cases of harm might be underestimated in the data.

I am in the above cardiac category and found these figures shocking. You are right to say that this sort of knowledge would help people decide whether or not to accept the medication. I had declined them for about ten years but eventually asked myself why I was refusing something that was reputed to be of enormous benefit: well, these figures cast a different light.

I am glad that you brought them to my attention. Thank you.

Thank you.

by Penguin - 2024-07-22 14:09:25

Thank you for that Repero. I try to be fair minded, but completely understand why you reacted.

You're also quite right about the stats.  Meagre as they are! 

Good quality info for all is what I care about. I too can feel quite passionate about it. 

No hard feelings & best wishes to you. 

No hard feelings.

by Repero - 2024-07-22 15:06:03

We are all pretty passionate about this! Long may it continue.

Relative vs absolute risk reduction

by Rch - 2024-07-24 02:14:28

Big pharma and the U.S. medico-legal system thrive on relative risk reduction as opposed to absolute risk reduction. If an experimental group on a drug has 1 patient out of 100 with an event over an X period of study, and the control arm without the drug has 2 events out of 100, then wow!!, we have 50% risk reduction on the drug. Patients then pay an arm and a leg to the big pharma to reduce the relative risk of 1 event/100. The 98/100 in the control arm who didn't take the drug and suffered no events are just a background noise and simply ignored!! 

On a different note, simple lifestyle changes and moderate exercise are known to reduce all cause mortality significantly across all age groups and gender, and certainly a complement or alternative to cost prohibitive drugs. 

Rch

by Penguin - 2024-07-25 18:10:28

Thank you Rch for your comment and thank you for using the appropriate terminology, e.g. relative risk vs absolute risk reduction. Well put and succinctly explained! 

I missed your comment, because we no longer get notifications, but I appreciate your comment and agree with you regarding lifestyle adjustments and the positive effect they can bring without medication which has it's place, but which isn't always necessary. 

Best Wishes 

Btw: I enclose a link to an NHS clinic in the UK (GP surgery) who cite the NNT to inform their patients about statins and what the statistics actually mean to them. 

https://www.cowleyroadmedicalpractice.org.uk/clinics-services/nhs-health-check-qrisk/

Thanks Rch

by Repero - 2024-07-26 05:47:15

Thanks for that clear explanation of risk.

The GP link that Penguin has just provided includes the following summary for patients considering whether or not to take a statin:

"To prevent one cardiovascular event in people with a risk of 10% 167 would have to be treated with a statin for 5 years. For a risk of 20% the number needed to treat is 67. This means that most people who take a statin derive no benefit (but may experience side effects)."

The "risk" mentioned above is the Qrisk score.

May I ask whether, in your opinion, we should be concluding that cholesterol was never a significant problem in the first place? Based on the evidence that reducing it doesn't really change anything much.

The one thing we can't do anything about is our age. In later life it seems to be age that largely determines our Qrisk score, so taking medications looks a bit irrelevant - is that an exaggeration?

Thanks.

Repero

by Penguin - 2024-07-26 16:44:38

Not sure if Rch will see this as the thread as it is getting a bit old and long! 

I'm happy for you to make it into a new thread and cite pieces from this one, if you don't get a reply and want to explore the cholesterol issue further or take it in your own direction. 

I'd be happy to comment and read what others have to say.  I too have questions about the validity of monitoring cholesterol. 

Best Wishes