Do you remember when we talked last year about the purpose of preventive medicine?  Then you remember that the point of blood pressure medicine isn’t to lower blood pressure, it’s to prevent strokes and heart attacks.

There are now many blood pressure medicines that have been proven to prevent strokes and heart attacks and have track records of safety lasting decades.  These older medicines are also available generically and so are fairly inexpensive.  That’s a tough market to break into.

So new blood-pressure medications have to justify their higher price tags by proving that they have fewer side effects or are more effective than their older competitors.  Micardis (telmisartan) is a blood pressure medicine in a family called angiotensin receptor blockers (ARBs).  The novel mechanism of ARBs raised hopes that it would prevent strokes better than other blood pressure medicines.

A study published this week in the New England Journal of Medicine tested that hope.  Patients who had had a recent stroke were randomized to Micardis or placebo.  Other blood pressure medications were used as needed to control blood pressure.  The patients were followed to count the incidence of a second stroke.  The disappointing outcome was that the patients on Micardis had as many strokes as patients on other medications.

Just yesterday the pharmaceutical representative who gives our office samples of Micardis came by and told me how well Micardis is tolerated and how well it lowers blood pressure.  She didn’t mention that study at all.  I wonder why.

Learn More:

Washington Post article: Newer Blood Pressure Drug No Better Than Placebo in Preventing Stroke

New England Journal of Medicine article: Telmisartan to Prevent Recurrent Stroke and Cardiovascular Events

The New England Journal of Medicine and the Massachusetts Medical Society released a video this week of a panel discussion on U.S. health policy.  I thought it was a fascinating and intelligent discussion by representatives of all the stakeholders in the debate.  The discussion covers many topics critical to American healthcare, including the dwindling numbers of primary care physicians, adoption of electronic medical records, providing care to the tens of millions of uninsured, and the escalating costs of healthcare.

This is a handy primer on a topic that will become increasingly important in the next decade.

The video is about an hour long, and is open to non-subscribers.

Shattuck Lecture:  Health of the Nation – Coverage for All Americans

Coronary angioplasty is a technical marvel.  A thin tube is threaded from an artery in the groin to the heart.  Through this tube a tiny balloon is threaded into a narrowed coronary artery.  The balloon is inflated to open the artery, and then a stent (a metal mesh tube) is placed in the newly open artery to keep it open.  About a million coronary angioplasties are done in the United States annually.

The procedure was initially developed with the hopes that opening narrow arteries would prevent heart attacks and save lives in people with chronic coronary disease (narrowing of the coronary arteries).  Alas, that’s not the case.  Every study that has compared angioplasty to optimal treatment with medications has found no difference in the rates of heart attack and death between the two.  The largest such study was published in April of last year.

This was a major disappointment for proponents of angioplasty.  Angioplasty is a proven life-saver and is the treatment of choice in acute heart attacks, so it was hoped that it would also be life-saving in people at high risk for a heart attack with chronic coronary disease.

Part of the problem is the remarkable improvements in medical treatment of heart disease.  Optimal medical treatment now includes a cholesterol-lowering medicine in the statin family, aspirin, a beta blocker and an ACE inhibitor (two different families of blood pressure medicines).  Each of these families of medicines has been proven to prevent heart attacks.  The outlook for patients on this regimen is so good that it’s difficult for a new proposed treatment to do even better.

The proponents of angioplasty then argued that though angioplasty may not be life-saving, it helps quality of life by eradicating chest pain in patients with chronic heart disease.  A follow up study published this week in the New England Journal of Medicine examined that assertion.  It randomized patients with chronic heart disease to angioplasty with optimal medications or optimal medications alone, and followed the quality of life and the amount of chest pain in both groups.

The good news is that both groups steadily improved and did well overall.  The patients who had angioplasty had less chest pain about a year after angioplasty, but that difference disappeared by three years after randomization.

The bottom line is that angioplasty should be reserved for patients having an acute heart attack or for patients with chronic chest pain whose symptoms are not well controlled on optimal medications.

Learn more:

Associated Press article: Drugs as good as stents for many heart patients

The New England Journal of Medicine article in 2007 demonstrating that angioplasty does not save lives or prevent heart attacks: Optimal Medical Therapy with or without PCI for Stable Coronary Disease

This week’s New England Journal of Medicine article: Effect of PCI on Quality of Life in Patients with Stable Coronary Disease

Two years ago I wrote about the controversy of routine screening for prostate cancer.  Screening for prostate cancer is usually done with a blood test called PSA.  But whether diagnosing prostate cancer early helps patients is still unknown, and there are many serious complications that result from prostate cancer treatment.  That’s why in many cases of prostate cancer watchful waiting is a reasonable choice.

The U.S. Preventive Services Task Force recently reviewed the existing evidence for and against prostate cancer screening and published their recommendations in this week’s Annals of Internal Medicine.  Their findings drew much media attention.

The new USPSTF recommendations still state that there is insufficient evidence to recommend for or against screening for prostate cancer in men 50 to 75.  But the recommendations recommend against screening for prostate cancer in men 75 and older.

There are ongoing studies now that will answer definitively whether diagnosing prostate cancer early helps.  Until those results are available, men over 75 should review these recommendations and discuss them with their doctor before making a decision about whether to have a PSA.  The test may lead to much more harm than benefit.

Learn more:

Washington Post article:  U.S. Panel Questions Prostate Screening

Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement

Some of my previous posts about prostate cancer:
The Controversies of Prostate Cancer Screening
Fighting Prostate Cancer by Doing Nothing

Tangential miscellany:

Last week’s post, The Exercise Transformation, elicited many responses.

Three readers suggested that being accountable to someone else is the key to making exercise a habit.  To that end, they recommended hiring a personal trainer, so that each episode of exercise is an appointment with someone else and is therefore harder to postpone or cancel.

Two readers thought that recommending 30 minutes of exercise on most days is a very intimidating goal for someone sedentary, and that success would be more likely to be achieved with a less ambitious initial goal, for example 10 minutes three times a week.  Once this easier schedule becomes a habit, the duration and frequency can slowly be increased.

My only disagreement with that reasonable suggestion is that I’ve had several patients tell me that the only way to make something a habit is to do it almost every day.  Even though the cardiovascular benefits of exercise only require 30 minutes of exercise three times a week, this may be harder to sustain psychologically than a daily habit.  Ultimately, I would recommend whatever works for each person.  If doing something every day seems like an insurmountable initial goal, start slower.

Finally, a reader wrote to extol the power of just showing up.  She said that when she doesn’t feel like exercising, she talks herself into it by just putting on the swimsuit and getting to the pool.  Once there, the actual swim doesn’t seem as daunting.

I’m grateful to everyone who emailed.

I usually write about an item in this week’s news or in the recent medical literature.  Forgive me from straying from that path this week to share some personal reflections.

For sedentary patients there is an enormous psychological barrier to exercise.  All primary care doctors face that barrier daily.  We encourage, cajole, practically shove our patients to become more physically active.  The vast majority of the time, despite the patient’s and the doctor’s best intentions, no change occurs.  The patient never starts exercising, or abandons his efforts after two or three days.  Habits are very hard to change.

This is very frustrating for both the physician and the patient.  Physicians knows that cardiovascular exercise lowers blood pressure, lowers blood glucose, improves mood and energy, lowers cholesterol (while increasing, HDL, the good cholesterol), decreases anxiety and improves sleep.  The scientifically proven benefits of cardiovascular exercise exceed those of many medicines and tests that we use routinely.  Patients know this too.  They know they should be exercising, but they can’t overcome the sedentary inertia.

Patients always have excellent reasons why they can’t exercise.  Usually they’re too tired or too stressed.  This is a trap, a spiral that inevitably leads to less and less activity which causes more fatigue and more stress.  The irony is that the most effective remedy for fatigue and stress (assuming serious medical and psychiatric problems are ruled out) is exercise.  So the only way to break out of the trap is to start exercising despite the fatigue and despite the stress.  “Just start exercising anyway”, doctors beg.

Don’t misunderstand; I’m not trying to get patients to compete in triathlons or climb mountains.  I just want them to start walking for 30 minutes on most days.  Shopping, chasing your kids and walking around in the office do not count.  You have to be walking just to walk.

Then, in a tiny number of cases, through psychological processes that are completely mysterious to me, a miracle happens.  A patient starts exercising.  The transformation is unbelievable.  His blood pressure drops a few points.  A few pounds are shed.  Her heartburn resolves.  And even more impressive than the physical effects are the mental benefits.  Patients tell me they can concentrate better.  They’re less anxious.  They feel great!  After a few months, they can’t imagine skipping their exercise.  It just feels too good.  It’s as much a part of their routine as showering and dressing.  It’s a habit.  Habits are very hard to change.

In the last year I’ve told three of my patients that they are on the borderline of developing diabetes.  They have each, in his own way, made the exercise transformation.  All three are more active, leaner and happier.  For the time being, none of them needs medications for diabetes.

How can doctors better encourage that transformation?  I wish I knew, and I’d love your suggestions.  All I can recommend is that you pick something you like, start slowly, do it for at least 30 minutes almost every day, and start today.