TEC: Evidence Based Therapeutics
Therapeutics Education Collaboration
Medication Mythbusters – Home of the Best Science (BS) Medicine Podcast

The BS Medicine Podcast episodes are presented by James McCormack and Michael Allan. We try to promote healthy skepticism and critical thinking and most of the podcasts are presented in a case-based approach. We also try to inject some humour into the whole process to make the learning more interesting. Occasionally we have great guests like Mike Kolber, Tina Korownyk and Bruce Arroll help us out.

Most podcast episodes are available for free until they become archived after about 1-2 months. Every 4th episode or so is a “New Studies You Need to Know About” podcast and these will only be available to our Premium Podcast members. Premium members will also be able to listen to all archived episodes since episode #1.

Episode 8: Taking the Pressure Off: Hypertension Drugs

In our eighth installment, we discuss the initiation of hypertensive drug therapy. In recommending thiazide diuretics, we outline the evidence (e.g. ALLHAT trial) showing equivalence and the significantly lower yearly cost. We debate (politely this time) dosing and attempt to dispel the smokescreen of thiazide metabolic issues (e.g. blood glucose). The usual banter ensues around the challenges of monitoring therapeutic effect and the pseudo-logic of initiating combination drugs.

Show Notes

1) ALLHATno difference in CVD outcomes between thiazides, ACEI or CCBs in hypertensive patients treated for 4.9 years

2) Additional benefits of ACEIs/ARBs on renal outcomes in diabetic patients is unproven

Lancet 2005;366:2026-33

3) No evidence of superiority of CCBs or ACEs over thiazides for hypertenison in type 2 diabetics

Arch Intern Med 2005;165:1401-9

Episode 7: Hypertension: Taking the Pressure Off

In our seventh installment, we discuss the options for blood pressure reduction before adding medications. We first talk about medicines, drug use and dietary factors that may increase blood pressure. We review the approach and potential benefits of varying lifestyle interventions like Exercise (e.g. pedometers), Diet (e.g. DASH) and Salt Reduction. The ever elusive balance between nagging and encouragement is debated (James and Mike pick sides).

Show Notes

1) Using a Pedometer

  • Ask the patient to wear the pedometer for one week
  • Have them calculate their “steps/day”
  • Next add 1000 steps to the day average and that will be their daily goal for each day next week.
  • They repeat this every week.
  • Once at 10,000 steps/day. They can stay stable (and come to see you to brag about their success)

NOTE: This is only one way. There are many and you should feel free to use any safe approach to help you patients increase their activity.

2) Approximately 35% of patients who reduced their salt intake either

had no change in blood pressure (20%)

or an increase in blood pressure (15%)

Hypertension 2003;42:459-67

Episode 6: Hypertension: Coping with the Pressure

In our sixth installment, we begin to discuss hypertension. We review the principles of making the diagnosis of hypertension and confounders in the office. Although the identification of an elevated blood pressure for a certain patient may be new, the hypertension itself is likely not and rarely an emergency. The risks of hypertension are put in context of global cardiovascular risk while we wax poetically around evolving hypertension guidelines.

Show Notes

1) Our 45 y/o 10-year risk

Framnigham
10 year change of CVD
Overall CVD 14.1%
CHD 12.3%
MI 6.4%
Stroke 1.2%
Death of CVD 2.0%
Death for CHD 2.0%

2) Treating a Blood Pressure of 160 /100 mmHg for 5 years –

 

CVD ? 1% (4% to 3%)

3) Diagnosis of high blood pressure

Elevated BP Measured

Episode 5: Swiss Cheese & The Evidence Holes in the Lipid Hypothesis

In our fifth installment, we end our discussion of cholesterol outlining some of the remaining evidence gaps. Areas discussed are primary prevention for women, the use of other cholesterol reducing medicines, and the need for follow-up cholesterol testing for patients on statins. We avoid filling the evidence gaps with theory-based assumptions and close by discussing the endless fun in tests, doctors’ visits and taking medicines.

Show Notes

1) Absolute benefit of statins over approx 5 years

Major coronary events (%)* Death (%) Strokes (%) FROM WHAT CVD TO WHAT CVD (%)
Primary 1-1.5* 8-9 to 7
Diabetes 2 1-1.5 10 to 7
Secondary 4 2 1 20 to 15

* just in males and NO difference in overall serious adverse events

2) Meta-analysis data for mortality benefit with Statins in primary prevention

3) Ezetrol data

4) Fibrate data

5) Torcetrapib

6) Treating to Targets

  • Optimal targets “because all of the trials compared fixed-dose regimens of more intensive statin therapy with less intensive statin therapy and because none provided a breakdown of event rates by the level of LDL cholesterol reduction achieved, the available data cannot be used to define optimal target LDL cholesterol levels.”
  • No long-term data for adding other cholesterol meds to statins in order to hit targets “It is not enough that short-term trials with LDL cholesterol outcomes have demonstrated that other lipid-lowering agents can further lower LDL cholesterol when given along with statins. Large trials are needed to establish the clinical safety and effectiveness of combination therapy.”
  • High vs low dose statins in primary prevention. “the current literature provides limited insight into whether more intensive statin therapy should be used in patients without coronary artery disease but with multiple atherosclerotic risk factors” CMAJ 2008;178(5):576-84

Episode 4: De-constructing Risk (or Benefit)

In our fourth installment, we apply the absolute benefit for statin therapy to our patient. We discuss the absolute benefits in context of the individual risk and acknowledge that when translating pooled literature numbers to individual patients an element of mysterious uncertainty always remains (except for James who knows but won’t tell and Mike who doesn’t know but tells us he does).

Show Notes

Definitions

CVD is cardiovascular disease and typically refers to the combination of CHD (coronary heart disease – fatal and non-fatal MIs and sometimes angina) PLUS cerebrovascular disease (fatal and non-fatal strokes – and sometimes TIAs) PLUS (sometimes) other conditions (heart failure, peripheral vascular disease)

Calculating benefit

  1. Change the factor and recalculate the chance of CVD
  2. Use the relative benefits seen in clinical trials (typically 5 years in duration) and apply them to the chance calculated for your patient
  3. Avoid the use of CDV calculators and just use the absolute benefits seen in clinical trials

A synopsis of the relative benefit of drugs

  • Statins ? 30%? in CHD (0%? in women)? 5 years
  • BP ? 40 %? in strokes and ? 20%? in CHD ? 5 years
  • Metformin ? 35%? in CHD and stroke ? 8-10 years

A synopsis of the absolute benefit of drugs

Statins over 5 years in a post MI patient Coronary events ?4% (15% to 11%) Death ?2% (12% to 10%) Strokes ?1% (5% to 4%) Treating a Blood Pressure of 160 /100 mmHg for 5 years CVD ? 1% (4% to 3%)

Absolute benefit of statins over approx 5 years

Major coronary events (%)* Death (%) Strokes (%) FROM WHAT CVD TO WHAT CVD (%)
Primary 1-1.5* 8-9 to 7
Diabetes 2 1-1.5 10 to 7
Secondary 4 2 1 20 to 15

* just in males and NO difference in overall serious adverse events

Episode 3: The Risky Business of CVD Risk Assessment

In the third session, we discuss the advantages and disadvantages of three methods to present “benefit”: changes in risk calculators, using relative risk, or the absolute benefit. We review the challenges of absolute vs relative risk (or relative vs absolute truth) and discuss patient expectations in regards to the medical miracle of prevention. The duration of therapy is put in context of the epoch time frames of risk calculators and studies.

Show Notes

Definitions

CVD is cardiovascular disease and typically refers to the combination of CHD (coronary heart disease – fatal and non-fatal MIs and sometimes angina) PLUS cerebrovascular disease (fatal and non-fatal strokes – and sometimes TIAs) PLUS (sometimes) other conditions (heart failure, peripheral vascular disease)

Calculating benefit

  1. Change the factor and recalculate the chance of CVD
  2. Use the relative benefits seen in clinical trials (typically 5 years in duration) and apply them to the chance calculated for your patient
  3. Avoid the use of CDV calculators and just use the absolute benefits seen in clinical trials

A synopsis of the relative benefit of drugs

  • Statins ? 30%? in CHD (0%? in women)? 5 years
  • BP ? 40 %? in strokes and ? 20%? in CHD ? 5 years
  • Metformin ? 35%? in CHD and stroke ? 8-10 years

A synopsis of the absolute benefit of drugs

Statins over 5 years in a post MI patient Coronary events ?4% (15% to 11%) Death ?2% (12% to 10%) Strokes ?1% (5% to 4%) Treating a Blood Pressure of 160 /100 mmHg for 5 years CVD ? 1% (4% to 3%)

  • Therapeutics Letter #62.
  • Absolute benefit of statins over approx 5 years

    Major coronary events (%)* Death (%) Strokes (%) FROM WHAT CVD TO WHAT CVD (%)
    Primary 1-1.5* 8-9 to 7
    Diabetes 2 1-1.5 10 to 7
    Secondary 4 2 1 20 to 15

    * just in males and NO difference in overall serious adverse events

    Episode 2: Evidence does not equal decision-making

    In our second session we discuss the philosophy of calculating risk and the many factors that influence the application of these numbers. We each calculate risk using our personal preference for risk estimators and discuss the mystery of why these numbers are not the same. “Treating” asymptomatic patients and instituting preventive interventions taken for a life time does not require great haste.

    Show Notes

    Canadian Cardiovascular Society Risk Calculator

    12 points =10% risk in 10 years (of non-fatal MI or coronary death)

    Risk factors Points
    Age 3
    Total cholesterol 6
    HDL 2
    BP 1
    Smoke 0
    TOTAL 12

    Can J Cardiol 2006;22(11):913-27

    Our 45 y/o 10-year risk

    Framingham
    10 year chance of CVD
    Overall CVD 14.1%
    CHD 12.3%
    MI 6.4%
    Stroke 1.2%
    Death of CVD 2.0%
    Death for CHD 2.0%

    Episode 1: Philosophy, guidelines and the truth

    In this first session we offer a slightly long introduction (but not long enough to reach REM sleep). We present Mr. Guy Lines, a 45 year old male with a number of risks for cardiovascular, who we will consider over the next number of sessions on primary prevention. We lay the rocky groundwork of future podcasts; touching on patient values, the arbitrary nature of guidelines, discussing risks, the asymptomatic ‘sick’ patient, and the art (or enigma) of applying the evidence.

    Show Notes

    Hippocrates would be proud?

    Mr G. Lines is a 45 year old male in for his “periodic” health exam. He describes himself as happy and healthy Aside from reminding him to wear a seatbelt, floss regularly, etc, you find…

    1. He is relieved to hear routine rectal exams don’t start until age 50
    2. His BP is 146/85 today (you took it twice hoping it would be below 140)
    3. His BMI=29 and his WC=98 cm
    4. His Lipids: Total Cholesterol = 6.8/265, HDL = 1.0/39, LDL = 4.9/191, Trig = 2/312
    5. His Blood Sugar = 6.4/115
    6. He is not a smoker

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