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

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I would discount what this article says about cholesterol. It sounds like a bid to get more people into the doctor's office and on statin drugs. The studies do not show that elevated cholesterol causes heart disease. In the big Framingham study, for example, "high" cholesterol was no predictor of heart problems in men over 47--quite the opposite: low cholesterol was the indicator of problems.

Studies of Canadian and Russian men also showed that cholesterol was no risk factor. Most studies show that it is no risk factor in women.

The French eat a high-fat diet and have little heart disease. Etc., etc., etc. The hypothesis is full of holes.

When a correlation does appear, it is weak, with a co-efficient of 0.36. A perfect correlation is 1.0.

For details on this and more, see Uffe Ravnskov's The Cholesterol Myths.

Sheldon

I find the tone of this report really disturbing. They've equated 'getting treatment' with 'going on medication.' Interesting how they've tossed proper diet, exercise, the processed food issue, etc as one final breif paragraph.

The more I re-read this article, the more skeptical I become. It's a plan to medicate everyone! Consider the case above. If the second person has no hypertension, but smokes, drinks heavily, and is overweight, why wouldn't this person be advised to stop smoking, cut his drinking, and lose weight? What possible reason would there be to put him on BP medicine?! (His BP is normal and all BP medicine has side effects.)

This is such a naked bid for patients it is ridiculous. Are the doctors determined to make eveyone totally lose confidence in them? So be it.

Sheldon

You guys are SO correct. I work as a nurse practitioner in the VA and the pressure is ON! (Not just for the VA, either) The buzzword in medicine now is prescribe, prescribe, prescribe! We are becoming lax in trying to modify risk factors that can be modified. It's easier, too, just to give a pill.

This type of "advertising" coupled with the real advertising that drug companies do on TV has an added downside - many folks come in to the office demanding to be put on "that pill; you know, the one they talk about on TV".

I will say, too, most of the people I deal with are NOT going to modify anything. Too much trouble, they're too busy, etc, etc. They just want that magic pill.

So mainstream medicine is accomodating them royally. I wear myself out daily trying to get through to people about healthy choices. Some listen, most don't.