Ask doctors what key measurements they rely on to assess the overall health of a patient and you are likely to hear about high cholesterol and blood pressure. Elevated blood sugar is not far behind. Controlling these key metrics is considered essential for good health. In general, the prevailing belief is that high cholesterol and blood pressure must be brought into the normal range. Lower is almost always thought to be better.
What About Lifestyle Changes?
We frequently see guideline committees give lip service to lifestyle changes. That’s a step in the right direction. Unfortunately, there are relatively few physicians who have been trained as health coaches. In practical terms, they do not have the skills or the time to motivate, monitor and facilitate exercise, weight loss and healthy eating strategies.
Because these kinds of lifestyle changes are hard for people, they often are not able to lower their high cholesterol and blood pressure into the normal range. As a result, getting high cholesterol and blood pressure lower almost always boils down to prescriptions for medicine.
The Battle Begins:
When you delve into the details of controlling high cholesterol and blood pressure, you discover that there are different health perspectives. Sometimes patients feel as if they are caught between warring camps. How high is too high? What’s considered normal? How low should cholesterol, blood pressure and blood glucose go? Physicians do not always agree.
Lies, Damned Lies and Statistics:
You’ve no doubt heard the phrase, “Lies, damned lies, and statistics.” It implies that people can manipulate numbers to mislead.
Mark Twain used the phrase enough that many people have attributed it to him. In truth, no one seems to know who first coined this term.
According to Wikipedia, the first time this saying was found in print was in the National Observer, a British newspaper. A letter to the editor was published on June 13, 1891, stating:
“Sir, —It has been wittily remarked that there are three kinds of falsehood: the first is a ‘fib,’ the second is a downright lie, and the third and most aggravated is statistics.”
These days scientists have another way of describing misleading statistics. It is called confirmation bias. In other words, we see what we want to see and ignore that which does not conform to our perspective.
The ancient Athenian historian Thucydides wrote about this problem over 2000 years ago. Here are some quotes attributed to Thucydides
“…the search for truth strains the patience of most people, who would rather believe the first things that come to hand.” [Wikipedia]
Then there is this one:
“It is the habit of mankind to entrust to careless hope what they long for, and to use sovereign reason to thrust aside what they do not desire” [goodreads]
High Cholesterol and Blood Pressure:
Most patients assume that health professionals are in agreement when it comes to treating high cholesterol and blood pressure. These are, after all, the pillars of standard medical care.
The Cholesterol Conundrum:
Let’s start with cholesterol. The American College of Cardiology (ACC) and the American Heart Association (AHA) issued guidelines in 2013. The recommendations would put nearly all men over 64 and women over 70 on a statin-type cholesterol-lowering medicine. That’s even if they:
- Do not smoke
- Have no family history of heart attacks or strokes
- Exercise regularly
- Follow a heart healthy diet
- Have beautiful numbers like total cholesterol of 180, blood pressure of 120/75 and no signs of heart disease.
The guidelines issued by the ACC and the AHA were presumably based on science. The cardiologists reviewed the literature and came up with their recommendations. We know these well-meaning health professionals want to prevent heart disease. The only problem is that there are other well-meaning physicians who have also reviewed the literature and come up with different conclusions.
A Contrarian View of Cholesterol:
Most health professionals welcome guidelines for prescribing medications like statins. But some have examined the same evidence and come to different conclusions.
One cardiologist and lipid specialist has challenged his colleagues. He suggests that they may be swayed by confirmation bias (QJM, online Nov. 2, 2017).
When it is done consciously and deliberately, we might call this type of selectivity regarding studies “cherry-picking.” But Dr. Robert DuBroff is accusing the guideline writers of something less malicious but more insidious: gravitating to the evidence that supports their position and overlooking data that might refute it.
Dr. DuBroff notes that:
“For example, in one randomized controlled trial (RCT) there was no benefit of atorvastatin therapy in extremely high risk asymptomatic patients with coronary calcium scores >80th percentile. Similarly, selected RCTs of statins in other high-risk populations – diabetes mellitus, chronic kidney disease, ischemic heart failure, post-MI [myocardial infarction], and post-CABG [coronary artery bypass graft] – have also reported no clinical benefit.”
Statins and Older People: The Controversy Rages On
Many older people are prescribed statins in the hopes that drugs like atorvastatin, lovastatin, rosuvastatin and simvastatin will prevent cardiovascular (CV) events and reduce mortality. Dr. DuBroff takes a colleague to task:
“The former president of the National Lipid Association advocated for statin usage in the elderly in his 2015 Journal of the American College of Cardiology editorial. He cited the PROSPER study, a RCT [randomized controlled trial] of statin therapy in the elderly, which reported a reduction in CV events but not mortality.
However, he neglected to reference the only other published RCT of statins specifically in older patients (CORONA) that reported no significant reduction in mortality or CV events.”
Dr. DuBroff points out that physicians often become overwhelmed by all the studies, guidelines, medications and warnings. They look to experts for informed opinions:
“They expect these opinions to be comprehensive, balanced, unbiased, and unsullied by financial conflicts. Unfortunately, these examples illustrate that some expert opinions fall short of these standards. Furthermore, recent reviews affirming the benefits of cholesterol reduction have largely ignored nearly four dozen RCTs of cholesterol lowering that have failed to reduce mortality or cardiovascular events. To ensure balance and fairness medical experts must incorporate the entire empirical record, not simply the evidence that substantiates their own viewpoint. We must also acknowledge that financial relationships between the pharmaceutical industry and some medical experts can engender both conflicts of interest and bias that can jeopardize the credibility of their opinions.”
Other Cardiology Voices:
Dr. DuBroff is not the only cardiologist challenging the statin enthusiasts. An editorial in JAMA Internal Medicine by cardiologist Rita Redberg and her colleague Dr. Mitchell Katz is titled “Statins for Primary Prevention: The Debate is Intense, but the Data Are Weak” (Nov. 15, 2016). They examined the data and concluded:
“Using the current data, the decision aid shows that of 100 people who take a statin for 5 years, only 2 of 100 will avoid a myocardial infarction [heart attack], and 98 of the 100 will not experience any benefit. There will be no mortality benefit for any of the 100 people taking the medicine every day for 5 years. At the same time, 5 to 20 of the 100 will experience muscle aches, weakness, fatigue, cognitive dysfunction, and increased risk of diabetes.”
Let’s put this in a somewhat less scientific arena, such as horse racing. If we asked you to bet a month’s salary on a long-shot horse that had a 1 in 50 chance of winning the big race, you might think twice about betting. If only 2 healthy people out of 100 will avoid a heart attack after five years of statin treatment, that’s a 1 in 50 chance of success.
Of course, what people really want is to delay their likelihood of dying prematurely. According to Dr. Redberg, the odds that statins can do that are hard to detect. This is for what doctors call “primary prevention.” Except for elevated cholesterol levels, they are otherwise healthy. The story is more complicated for those with heart disease.
Lowering High Cholesterol AND Blood Pressure:
Cholesterol is not the only arena in which confirmation bias might have shaped recommendations. The most recent guidelines from the American Heart Association and the American College of Cardiology urge doctors to make sure all their patients get their blood pressure to 130/80 or lower (Circulation, Nov. 13, 2017).
This goal, 10 points lower than previously recommended, will be a challenge for many people. Of course, if it prevents large numbers of strokes and heart attacks, it will be worth the effort. To achieve the lower than 130/80 goal, patients may have to take many blood pressure medications.
A Different Perspective:
How confident should we be about the benefits of lowering blood pressure to this point? A meta-analysis published in JAMA Internal Medicine (Nov. 13, 2017) indicated that such an aggressive approach might not save lives.
These researchers found that lowering systolic blood pressure (SBP) over 140 before treatment did make an important difference. But otherwise healthy people whose SBP started under 140 did not appear to benefit from medications to lower it further.
A Heretical Analysis of Blood Pressure Treatment:
The highly regarded Cochrane Collaboration uses strict criteria to evaluate medical research. On August 15, 2012, this independent organization published a challenging article titled “Benefits of Antihypertensive Drugs for Mild Hypertension Are Unclear.” The conclusions:
“Antihypertensive drugs used in the treatment of adults (primary prevention) with mild hypertension (systolic BP 140-159 mmHg and/or diastolic BP 90-99 mmHg) have not been shown to reduce mortality or morbidity in RCTs. Treatment caused 9% of patients to discontinue treatment due to adverse effects. More RCTs are needed in this prevalent population to know whether the benefits of treatment exceed the harms.”
A Newer Cochrane Analysis of BP Treatment:
The objective investigators at the Cochrane Collaboration recently tasked themselves with an important challenge (Cochrane Database of Systematic Reviews, Aug. 16, 2017). They noted that most of the systematic reviews of antihypertensive drug therapy have been done in people over the age of 60. They wanted to know the impact of drug treatment on people 18 to 59. With the new guidelines, a great many of these folks will likely be put on BP meds. How good is the evidence that such treatment will produce meaningful benefit?
The Cochrane researchers located seven studies involving 17,327 participants. These were healthy people with mild to moderate high blood pressure. Here is what they found:
“Based on five studies, antihypertensive drug therapy as compared to placebo or untreated control may have little or no effect on all-cause mortality (2.4% with control vs 2.3% with treatment; low quality evidence; Based on 4 studies, the effects on coronary heart disease were uncertain due to low quality evidence. Low quality evidence from six studies showed that drug therapy may reduce total cardiovascular mortality and morbidity from 4.1% to 3.2% over five years…The effects on blood pressure varied between the studies and we are uncertain as to how much of a difference treatment makes on average.”
“Antihypertensive drugs used to treat predominantly healthy adults aged 18 to 59 years with mild to moderate primary hypertension have a small absolute effect to reduce cardiovascular mortality and morbidity primarily due to reduction in cerebrovascular mortality and morbidity. All-cause mortality and coronary heart disease were not reduced.”
The People’s Pharmacy Perspective:
The new guidelines from the AHA and ACC clearly contradict the Cochrane analysis. Which perspective is “right”? Perhaps neither, though we tend to believe the Cochrane independent investigators when they state repeatedly that the evidence is of “low quality.” In other words, decisions are being made for millions of people based on poor quality research. We were also astonished to read that “all-cause mortality and coronary heart disease were not reduced” after antihypertensive drug treatment.
Guidelines should not be treated like dogma. Whether it’s blood pressure, cholesterol or some other metric, physicians should consider each patient as an individual. Many people can tolerate statins and blood pressure medicines without experiencing any side effects. They lower their high cholesterol and blood pressure successfully and may reduce their risk of a heart attack or stroke. (Please note the word “may.” Given the Cochrane Analyses, this is not a slam dunk.)
Others, however, cannot tolerate statins. The muscle pain and weakness are daunting and prevent them from exercising. Some patients develop dizziness from too many antihypertensive pills. A fall can lead to disability or death. In such cases, other treatment options need to be explored.
Here are links to recent articles from The People’s Pharmacy:
You can find more information at: Graedons’ Guide to Cholesterol Control and Heart Health and Graedons’ Guide to Blood Pressure Treatment.
Share your thoughts about the Guidelines below in the comment section.