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Sun 20 Oct, 2002 11:37 am
Quote:WHO: Many doctors treating wrong patients to prevent heart attack and stroke
EMMA ROSS
Canadian Press
Friday, October 18, 2002
LONDON (AP) - Doctors in many countries are targeting the wrong people for treatment to avert heart attacks and strokes, a report by the United Nations health agency suggests.
Doctors are too prone to prescribe medication only for those with high blood pressure or high cholesterol, according to the World Health Organization, which will publish its World Health Report later this month.
Medication would be better targeted at those who have multiple risk factors such as smoking, lack of exercise, excessive alcohol consumption and poor diet, even if blood pressure or cholesterol levels are only slightly elevated, it said.
The main problem is that medication is usually prescribed only when blood pressure or cholesterol levels pass an arbitrary threshold, the report found.
For example, high blood pressure, or hypertension, is defined by a blood pressure of 140 over 90 or higher. Depending on the country, between 10 per cent and 30 per cent of adults have hypertension.
A blood pressure of about 120 over 80 is considered optimal.
The WHO report found that most people - perhaps 60 per cent worldwide - have elevated blood pressure that is not high enough to be labelled hypertension. They are sometimes in more danger of having a heart attack or stroke than people with hypertension.
A similar pattern occurs for cholesterol, said Dr. Anthony Rodgers, one of the report's authors. Cholesterol measurements that are considered average are actually usually too high for good health.
The WHO experts found that elevated blood pressure causes about half of all cases of heart disease worldwide. Elevated cholesterol causes about a third.
About three-quarters of all heart disease can be explained by known disorders, and only 25 per cent of cases are a mystery, the report said. That is far higher than the one-third to one-half of all heart disease cases commonly thought to be caused by blood pressure or cholesterol or other known risk factors.
"This evidence calls into further question the use of thresholds like hypertension when nearly all the population could benefit from lower blood pressure," said Rodgers, co-director of the clinical trials research unit at the University of Auckland in New Zealand.
"The global disease burden due to blood pressure is twice as much as previously thought," says Dr. Gro Harlem Brundtland, director general of the WHO.
People whose blood pressure lies between healthy and hypertension are not getting medications to avert heart attacks and strokes, even though they should, Rodgers said. And too many people not at great risk of heart trouble are getting treatment at the expense of those who need it more, he said.
For example, a 45-year-old man who has hypertension and is otherwise healthy usually receives medication. But his risk of a heart attack or stroke is less than that of a person who has elevated blood pressure falling short of hypertension, but who smokes, drinks heavily, is overweight and has slightly elevated cholesterol levels.
Doctors should look at a list of risk factors in each patient and prescribe medications to those who have multiple problems regardless of their blood pressure or cholesterol levels, WHO experts said.
The report recommends that people with multiple but individually mild risk factors take a daily combination of ASA, cholesterol-lowering drugs called statins and low doses of common blood pressure-lowering drugs.
The drug cocktail can more than halve the chances of a heart attack or stroke, could be much more widely used in the developed world and is increasingly affordable for poorer countries, the report says.
Dr. Thomas Kottke, a cardiovascular disease specialist and professor of medicine at the Mayo Clinic, said the United States is already moving in that direction.
"They are talking about a paradigm shift here of what we think about," said Kottke, who was not involved in the report. "Certainly there are trials that demonstrate this appears to be a good idea."
Pills are not the only solution, the report said. Nationwide strategies such as reducing the amount of salt in processed foods, higher taxes on tobacco to discourage smoking and encouraging better eating and exercise habits would also help.
© Copyright 2002 The Canadian Press
Are you aware of stroke or heart attack risk factors? Are you doing anything about it, and if so, what?
Very interesting Phoenix my personal opinion is that stress is the main problem causing disease in the US. In addition it is also my opinion that stress is what causes overweight problems, smoking, and drinking. Those individuals who smoke, drink, and that are over weight are unlikely to follow any regimen that would change there life style and prevent heart attacks. In addition, I think we, in the US are such a pill society, we want the quick fix which translates into taking a pill.
For me I have the luck of good genes but that is probably not enough. I have low cholesterol, normal blood pressure, and low weight and body fat ratio but my diet and exercise activity are not the best and heart attack is the number one cause of death in my family. Both of my parents had heart attacks, my father died during one but he was both a heavy smoker for probably 40 years or more and a heavy drinker. My mother survived her heart attack at age 62 and quit smoking but gained weight and developed diabetes after the heart attack and she never ever considered exercise as a factor in her life but did change her diet and lost the weight and the diabetes. She never had another heart attack and died when she was 80.
Joanne- One of the biggest problems in medicine today is the philosophy- "You break-we fix". There is very little that MDs do to PREVENT possible medical problems. In fact, the odds are really stacked against the doctors, because of the medical insurance companies. Insurance does not like to pay for preventative care. If there is no diagnosis, there is usually no payment.
I think that this is changing somewhat, where insurers are paying for certain medical tests. I remember, years ago, when I would go for a PAP smear. My doctor would always "make up" some cockamamie diagnosis, so that I would get reimbursed.
Years ago, maybe 20 or more, Medicare was blamed for the increase in ordering tests and increasing the numbers of people who sought medical care. I think there was some truth in that since prior to Medicare so many poor elderly folks could afford to go to a doctor. Now if you have Medicare it is difficult to find a doctor to treat you because they will not work for the caps.
Another issue is the advertising of drugs on TV. Two of my relatives are MDs and they say patients come in and insist on such and such drug because they saw it on TV. I have also been told by more than one doc that 90% of all people are healthy and really do not need any extensive medical care until after age 55. Yet these days we run to the doc for everything. They are afraid of malpractice so they order unnecessary tests it is like the tail chasing the dog.
When I worked for Navy Medical Command in D.C. we had a doctor one summer doing his weeks of reserve duty. It was the summer of 84 and HMOs were just starting up and DRGs where just being sorted out. I always remember him saying that with the advent of the HMO, medical service for profit would be the ruin of the profession.
One problem with the practice of medicine today, is that MDs are too quick to label a patient with a disease and then slap as Rx into his/her hands.
WRONG!
New Haven- what you have mentioned is the result of this "bargain basement" medicine that seems to be pervasive today. It is so much easier for a doctor to make a fast diagnosis, than really sit down with the patient, and really try to figure out what is wrong. The other problem is that some HMOs frown on doctors prescribing too many diagnostic tests.
Some health plans reward MDs , who keep the costs down.
Yes, the Insurance companies do frown on too many diagnostic tests.
The visit to the MD in managed care is supposed to last no more than 15 min. Think about the patient who visits the MD with the complaint of "I have had a heachace for the past 6 months".
Of the 15 min, about 6 min of that is actually spent "Talking" to the patient.
TROUBLE!
I have said it before, and I will say it again. The more knowledgable a patient is about doctors, hospitals, medications and illnesses, the better the chance that he will have to survive the medical crisis.
I have a doctor whom I consider very intelligent, and an excellent diagnostician. The problem is that over the last few years, he has become more and more hassled, and is out the door not too long after he steps in.
Why don't I change? Probably because I consider him the best internist in town. I have learned to get around his problem of his not being able to give a patient too much time. Before an appointment, I type all my concerns, as well as the prescriptions that I need. When he walks in to the examining room, I hand the paper to him.
In that way, we cut right to the chase, don't waste time, and he is able to address all my concerns.
Do you forsee a day, when internal medicine is practiced mainly via E-mail?
b
Phoenix:
Several programs that make the diagnosis are already available.
Virtual medicine willl replaced managed care, eventually.
Good or bad!
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