Blood pressure and cholesterol problems affect millions. These are the bread, butter and sugary drinks of Internal Medicine and general Cardiology practice.
It stands to reason then, that the treatment of these basic maladies would be well agreed upon. Guidelines and expert consensus statements would be clear and up-to-date.
But this is far from reality.
This recent story on theHeart.org chronicled the fact that treatment guidelines for high blood pressure and high cholesterol are a decade old. (And the last word on best practice for obesity treatment was 15 years ago.)
Surely this death of clarity is worthy of comment. A baker can bake bread and a mechanic can change the oil. A medical doctor should know how to treat high blood pressure and high cholesterol.
But the fact remains that we have no contemporary guidelines. Let me repeat: There is no expert consensus on how to treat blood pressure and cholesterol issues. Wow.
Itâ€™s worth thinking about why and how this came to be. Perhaps recent disruptions in dogmatic medical thinking have played a role?
Consider these facts:
- Weâ€™ve learned that treating to biomarkers (surrogate endpoints) isnâ€™t such a good idea. Witness niacin and HDL.
- Weâ€™ve also learned that strict control of blood pressure may worsen outcomes in diabetics and the elderly.
- Another shocker is that the common practice of titration to certain cholesterol levels has a dubious evidence base.
- The role of exercise has only complicated matters. Itâ€™s now clear that real exercise (that which makes one fit) is an effective and safe therapy. How does one work this pearl into the guidelines? How much adherence should a doctor expect before unleashing the pills-with-side-effects strategy?
- And nutrition: Will the guidelines say something about the fact that doctors canâ€™t stop patients from making bad food choices? Yes, we can click a box that says we discussed nutrition, but that doesnâ€™t make people eat well. And we don’t all live in NY city.
- The role of sleep. Ten years ago sleep disorders were not on the radar. Now, with the explosion of societal inflammation and obesity-thickened necks, sleep apnea has roared to epidemic-like prevalence. You canâ€™t be healthy without good sleep.
Yet none of these disruptions were cited as reasons for the delay. Rather, one of the co-chairs of the writing committee (a government agency) said the delay was due to lack of resources. The writing committee had to use video-conferencing rather than fly people in for a couple of days of meetings. Thatâ€™s funny.
I believeâ€”at least I want to believeâ€”experts are struggling with the less-is-more philosophy. Steve Stiles’ coverage on theHeart.org highlighted the problem of incorporating healthy lifestyles into the guidelines. How thought leaders handle this elephant in the room interests me immensely. Will they be strong and say that many (most) patients could avoid exposure to therapeutic harm if they made basic healthy lifestyle choices? Or will the un-inspiring vanilla language remain: â€œwhen lifestyle changes arenâ€™t effective, start with drug X, Y or Z?â€ Gosh, it would be disappointing if medical leaders fail to place the primary therapy of high blood pressure, high cholesterol and obesity on the patient rather than the doctor.
Donâ€™t misunderstand; there is a role for medical therapy here, especially in the secondary prevention of heart disease and stroke. I simply hope for a major change in philosophyâ€”away from pills and towards lifestyle choices.
Before concluding with dreamy optimism, there are two other possible factors in the delay of consensus statements:
The media situation is different now. Within seconds of hitting the publish button these documents will spread through social and mainstream media for analysis and commentary. Think amplify. Gone are the days when documents languished in medical journals. The writers must know this, and it must be a little scary.
I also wonder if guideline writers are considering the power they wield. Guidelines are no longer used only for guidance. Now, the noun â€˜guidelineâ€™ has morphed into â€˜rule.â€™ Guidelines quickly become boxes to click on EMR programs, quality measures, and soon, the number of patients a doctor has on certain drugs will become a means of compensation. Oh, what a bad idea that is.
Now for magical thinking:
Perhaps the guideline writers will throw up their hands and admit the truth: the treatment of high blood pressure, high cholesterol and obesity have grown so complicated and dependent on individual responsibility that we couldnâ€™t possibly offer any useful standard protocols? We offer no guidelines!
They will say that each patient must be assessed and therapy be individually directed and aligned with patient-centered goals. And that medicine is overused and lifestyle choices are underused.
Now that would be worth waiting for!