Can We Do Better?

A considerable number of strategies in American medicine are troubling.  One of the most troubling is our insistence on spending large amounts of resources treating illnesses that might be able to be prevented at an earlier stage.  Simple examples are providing better treatment of diabetes and hypertension by making the drugs and materials needed more readily available to patients.

As the readers of my blogs know, a large proportion of this country’s resources go to treating coronary artery disease and its consequences.  Couldn’t we do better if we prevented this?  Roughly 50% of the major cardiovascular events that occur in this country every year, which by the way amounts to over 700,000, occur without warning.  At the time of writing in 2006, it was felt that by implementing the SHAPE recommendations 21.5 billion dollars could be saved.

This subject has been discussed before.  In 2006 a taskforce was developed to address this problem and provided the SHAPE guidelines.  SHAPE stands for Screening for Heart Attack Prevention and Education.  It was a committee set up by big Pharma mostly Pfizer and never received much support mostly because it would make heavy use of drugs i.e. Lipitor, made by Pfizer, in its prevention mode.

This past week one of the editorial leaders of the SHAPE study Dr. Prediman Shah was the lead author on an article published in the Journal of the American College of Cardiology titled Screening Asymptomatic Subjects for Subclinical Atherosclerosis .  I want to point out that Dr. Shah, who practices at Cedars Sinai in Los Angeles, is a widely published and respected researcher.

Screening for disease, although it sounds like a perfect solution, is sometimes no solution at all.  One can point to the use of the PSA test for prostate disease.  Screening with it has not led to changes in the diagnosis of advanced prostate disease or lowered the death rate of prostate cancer.  Recently, the physician who invented the test wrote that he thought our use of it should be reevaluated.

SHAPE recommended that all asymptomatic men 45-75 years old and all women 55-75 years old be screened.  There are two main ways this is done.  The first is the Framingham Risk Score that I have blogged about in the past.  This score which identifies the risk of events in ten and twenty year periods has been found to be useful.  It is highly dependent on blood pressure and cholesterol values as those were the only modalities available at the time.  If you go to the online calculator fiddle with the numbers so you can see the changes in risk that occur.  Guess what?  This approach has never been subjected to a randomized clinical trial and at this point never will be because it is not ethical. 

Next…what about imaging?

Tags: SHAPE Guidelines

This entry was posted on Friday, July 16th, 2010 at 8:30 pm and is filed under Cholesterol, Coronary Artery Disease, High Blood Pressure, diabetes. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.