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Bleeding Disorders May Cause Menorrhagia and Postpartum Hemorrhage

A consensus meeting aimed to improve recognition of bleeding disorders as a cause of menorrhagia and postpartum hemorrhage so that effective disease-specific treatment can be provided.
"In those women who do have a bleeding disorder such as von Willebrand disease (VWD), there is an increased incidence of pathologic bleeding....The lack of a clinical tool for the objective assessment of abnormal reproductive tract bleeding and the lack of awareness of the potential of bleeding disorders to exacerbate or even cause abnormal bleeding leads to the underdiagnosis and suboptimal treatment of women with bleeding disorders."
Although menorrhagia or postpartum hemorrhage may result in considerable, clinically significant blood loss, congenital bleeding disorders exacerbating these conditions historically tend to be underdiagnosed, presumably because of lower awareness among obstetricians and gynecologists vs hematologists.
Clues suggesting the possibility of an underlying bleeding disorder include a family or personal history of bleeding events. Recognizing these clues should improve collaboration among obstetrician-gynecologists and hematologists, reduce diagnosis of "idiopathic" menorrhagia, and result in better management of reproductive tract bleeding events. Women who have these conditions should thereby have improved quality of life and school and work performance indicators.

Questions and Answers Addressed
1. What is menorrhagia?
Although menorrhagia is typically defined as more than 80 mL of blood loss per menstrual cycle, other indicative features are soaking through a pad or tampon within 1 hour, soaking through bed clothes, below normal ferritin levels, anemia, and pictorial blood assessment chart score of more than 100.
2. When should a gynecologist or obstetrician suspect a bleeding disorder and pursue a diagnosis?
Indicators suggesting an underlying bleeding disorder include menorrhagia since menarche, a family history of a bleeding disorder, or failed response to conventional management of menorrhagia.
Other indicators are a personal history of 1 or more of the following: epistaxis; notable bruising without injury; minor wound bleeding; bleeding of oral cavity or gastrointestinal tract without an obvious anatomic lesion; prolonged or excessive bleeding after dental extraction; unexpected postsurgical bleeding; hemorrhage from ovarian cysts or corpus luteum; hemorrhage requiring blood transfusion; and PPH, especially delayed PPH.
Even in the presence of gynecologic disease such as uterine fibroids, a bleeding disorder may contribute to menorrhagia.
3. What hematologic evaluations should be ordered, and when should they be repeated?
Platelet number and function and specific coagulation factor profile should be evaluated in consultation with a hematologist. Other tests should include complete blood cell count, activated partial thromboplastin time, prothrombin time, VW factor (VWF) measured with ristocetin cofactor activity and antigen, coagulation factor VIII, and fibrinogen.
If results of these tests are normal, women should undergo testing of platelet aggregation and platelet release. Although testing should not be delayed to coincide with menstruation, subsequent testing during menses should be considered if the first set of VWF levels is at the lower limit of normal.
Hormonal contraception should not be interrupted to permit testing.
4. How should menorrhagia be managed in women with bleeding disorders?
Tranexamic acid (1 - 1.5 g, 3 - 4 times/day) may be given before hematologic testing, although management is optimally started once the diagnosis is made. Nonsteroidal anti-inflammatory drugs should be avoided. Further management strategies differ based on whether future fertility and/or becoming pregnant soon are desired. A combination of therapies is often needed, and consultation with a hematologist is essential. Hemostatic treatment should start on the first or second day of menses.
5. How can PPH be prevented in women with bleeding disorders?
Hematology consultation and collaborative care are recommended. VWF levels should be determined. If the coagulation factor profile is not in the normal range by the third trimester, delivery should take place at a specialized center. If third-trimester VWF levels are 50 IU/dL or more, epidural analgesia/anesthesia may be considered safe for delivery; otherwise, appropriate hemostatic cover is required. Adequate venous access is needed during labor, and the third stage of labor should be actively managed.
6. What do we know about menorrhagia and RBDs?
Tranexamic acid and aminocaproic acid or desmopressin (DDAVP) is useful for the treatment of menorrhagia in combined factor V or factor VIII deficiency, but additional research is needed to determine its role in other RBDs. Patients should be treated with antifibrinolytic treatment and appropriate factor replacement when available.
"An awareness of bleeding disorders (such as VWD, RBDs, and platelet disorders) is an important asset for obstetricians and gynecologists," the consensus authors write. "These disorders remain underdiagnosed in women with menorrhagia and potentially in other cases of abnormal bleeding (such as PPH)....The authors of this consensus believe that these recommendations will aid obstetricians and gynecologists to better anticipate, prepare for, and manage cases of abnormal reproductive tract bleeding in women with bleeding disorders."

Clinical Context
RBDs are inherited autosomally, with prevalence ranging from 1 in 2 million for factor II and factor XIII deficiencies to 1 in 500,000 for factor XI and factor VII deficiencies. The number affected by RBDs around the world has reached approximately 7000, with the most common being factor XI deficiency. VWD affects menstruation and childbirth and may lead to unacceptable blood loss. Because of menses and childbirth, VWD is more likely to present in women vs men, although the prevalence is similar between the sexes.
This is a consensus panel review constructed by obstetricians and gynecologists with hematologists based on a 2007 meeting of the literature on VWD in women focusing on presentation, diagnosis, and treatment strategies.

Clinical Implications
• The prevalence of VWD in adult women with menorrhagia is 13%, increasing to 33% in adolescents, and diagnosis is made by assessing risk factors and performing hematologic evaluation.
• In women with VWD who desire fertility, medical management is recommended, and VWF level should be at least 50 IU/dL to prevent PPH.

Evidence-Based Catheter-Care Procedures May Reduce Bloodstream Infection Rate

Evidence-based catheter-care procedures regarding hand hygiene may significantly reduce the rate of catheter-related bloodstream infections (CRBSIs),
"...CRBSI are a well recognized problem in the intensive care unit (ICU)," write Walter Zingg, MD, from the University Hospitals of Geneva in Geneva, Switzerland, and colleagues. "A recent study, in the neonatal setting, found hand hygiene successful as a single intervention measure in reducing CRBSI when its promotion was guided by healthcare workers' perceptions and combined with organization at the workplace. On the basis of high incidence rates of CRBSI in previous surveys of the ICUs in our institution, we decided to conduct an interventional study using an educational campaign focusing on hand hygiene and catheter care."

"Evidence-based catheter-care procedures, guided by healthcare workers' perceptions and including bedside teaching, reduce significantly the CRBSI rate and demonstrate that improving catheter care has a major impact on its prevention," the study authors write. "Infection control efforts to improve the quality of hand hygiene and catheter care are essential elements for patient safety, not only for the reduction of CRBSI but also for other health care-associated infections."

Clinical Context
Risk factors for CRBSIs include long duration of CVC use, insertion site other than subclavian, overmanipulation of the CVC system, and heavy cutaneous colonization, as well as patient factors of illness severity and immunodeficiency. Strategies such as handwashing and the use of CVCs coated with antimicrobials have been examined as methods to reduce CRBSIs.
This is a study of the effect of an educational intervention on hand hygiene practice in ICUs and its impact on CRBSI rates and predictors of CRBSIs among patients in the ICU.

Clinical Implications
• Predictors of risk for CRBSIs in ICUs are hospitalization in a medical ICU, male sex, and baseline period.
• An educational intervention for ICU nurses and medical staff is associated with improved hand hygiene and reduced CRBSI rates.

Screening at 2 Months Identifies Most Women With Postpartum Depression

Using a well-child visit to screen for postpartum depression 2 months after delivery will catch the majority of women likely to develop the condition within the first 6 postpartum months, new research suggests.
Investigators at the University of Colorado Denver School of Medicine also found that using cues embedded in the electronic medical records of infants 0 to 6 months of age to remind physicians to screen new mothers is an effective method of detecting and referring those at risk.

No Optimal Screening Interval Identified
Postpartum depression is the most common medical problem new mothers face and is associated with a wide range of maternal and child health problems. It can develop any time during the first postpartum year, and while pediatric visits have been identified as an ideal setting in which to screen women, there is no evidence to support an optimal screening interval, the authors note.
The purpose of the study was to assess the feasibility of using electronically generated reminders to detect and refer at-risk women and to look at the prevalence and incidence of maternal depression assessed at well-child visits during the first 6 months after birth.
The study included 204 mothers and 413 electronic depression–screening cues. These prompts appeared automatically when the medical records of children 0 to 6 months old were opened and reminded medical staff to administer the 10-item Edinburgh Postpartum Depression Scale (EPDS) to new mothers.
Providers were unable to close the children's medical records until they had entered the EPDS score or 1 of the precoded reasons for not administering the EPDS.
An EPDS of 10 or greater was considered a positive result, and providers could not close the medical record until a management plan or referral was recorded.
The providers administered the EPDS 98% of the time and always referred mothers with positive scores. Overall, 20.1% of the women who completed the EPDS at 2 weeks, 2 months, 4 months, or 6 months had positive scores.
EPDS scores indicated that the prevalence of depressive symptoms varied from 17.0% at 2 weeks to 16.5% at 2 months.

Screening Before 2 Months Not Useful The researchers also found that screening for depression during the first 3 weeks was so unreliable that it could not consistently identify the same mothers as being at risk for depression. This finding, the researchers note, argues against routine, universal postpartum depression screening before 2 months.
After 3 weeks, the prevalence and incidence of positive EPDS scores decreased from 16.5% at 2 months to 10.3% and 5.7% respectively at 4 months. However, prevalence increased to 18.5% at the 6-month visit and incidence decreased to 1.9%, the investigators report.
If women had been screened only at the 2-month postpartum time point, only 2 of the 35 mothers with positive EPDS scores at 6 months would have been missed. Both of those mothers completed the EPDS within 3 weeks after delivery, but neither crossed the referral threshold.

Clinical ContextAll new mothers should be screened periodically for postpartum depression because it is treatable and common and has the potential to cause child health problems. Postpartum depression can occur any time during the first year, and the best screening interval and strategy have not yet been identified. Also, the prevalence and accuracy of screening at different times after delivery are not well reported.
This is a study of a screening program using electronic cues to providers of well-child visits in a pediatric clinic to examine the efficacy of the cue on screening for postpartum depression and the prevalence of postpartum depression in adolescent new mothers in the first 6 months after delivery.

Study Highlights
• The Colorado Adolescent Maternity Program is a comprehensive prenatal delivery and postnatal care program for 12- to 21-year-old mothers in 1 US state located in an urban hospital, serving a low-income population.
• Providers of well-child care were a pediatrician and 2 mid-level providers with training in adolescent medicine.
• An electronic medical record system is used for practice improvement, and all child health records were flagged electronically with prompts to providers to administer the EPDS to mothers of children at well-child visits.
• The EPDS is a 10-item validated and reliable scale with a score of 10 or higher reliably identifying 90% of cases in other studies.
• Responses were on a 4-point scale with a score range from 0 to 30, with higher scores indicating higher depressive symptoms.
• Mothers were given a pencil-and-paper version of the EPDS to complete while waiting for their child to be seen.
• Providers collected and scored the EPDS forms, discussed results with mothers, and recorded the scores in the children's electronic medical records.
• After 5 months, providers were unable to close the children's electronic records unless they had administered the EPDS at least once or given a reason why it was not administered.
• During the study period, providers saw 418 electronic screening cues for the EPDS associated with 204 mothers.
• In 5 cases, mothers were not with the child; of the remaining cues, providers responded to 99%.
• None of the mothers refused to complete the EPDS.
• Mean age of mothers was 18 years, 36% were black and 44% were Hispanic, 87% were Medicaid recipients, mean parity was 1.4, and 51% were living with a biological parent.
• Overall, 20.1% of mothers who completed the EPDS at 2 weeks and at 2, 4, and 6-month well-child visits met the referral criteria of a score of 10 or higher on the EPDS.
• The prevalence of depressive symptoms ranged from 17.0% at 2 weeks to 16.5% at 2 months to 10.3% at 4 months and 18.5% at 6 months.
• Although the prevalence was highest at the 2-week visit, this was the least reliable measurement because only 12% of mothers met depression referral criteria at 2 visits, and 8% resolved the symptoms at the following visit.
• The incidence of depressive symptoms decreased from 16.5% at 2 months to 5.7% at 4 months and 1.9% at 6 months, with only 2 cases that would have been missed if the mothers had been screened only once.
• 94.5% of the mothers who met the referral criteria did so at the first screening.
• The authors recommended that screening at 2 months identifies most mothers who develop postpartum depression and that screening at 6 months was preferable to screening at 4 months.
• Of 40 mothers who met referral criterion, 8.6% were 22 years or older.
• They were referred for further evaluation and treatment.
• The authors concluded that screening of mothers at the well-child visit in the first 6 months was feasible and was associated with an accurate diagnosis of postpartum depressive symptoms.

Clinical Implications
• Use of an electronic cue to providers for screening for postpartum depression using the EPDS in mothers at well-child visits is associated with high compliance by providers and mothers.
• The EPDS used at the well-child visit at 2 and 6 months is helpful for diagnosing depressive symptoms in new mothers.

Auto Insurance

Depending on the type of coverage you buy, auto insurance pays to fix your car if you’re in an accident, pays the medical costs of anyone you injure in an accident, and pays to repair other vehicles or property. The liability portion of your auto insurance policy covers you if you are found liable for causing injury or damage with your vehicle.
The six basic types of auto insurance coverage, according to the Insurance Information Institute are:
• Bodily injury liability -- covers injuries to other people.
• Medical payments, or personal injury protection (PIP) coverage -- covers injuries to yourself and your passengers. Sometimes lost wages and funeral costs also are paid by this type of auto insurance coverage.
• Property damage liability -- covers damage to other people’s property.
• Collision -- covers damage to your car from hitting another car or an inanimate object, or as a result rolling over. It even covers damage to your car from potholes.
• Comprehensive -- the catch-all auto insurance coverage for damage from hailstones, earthquakes, vandalism, theft or anything other than what’s covered under collision coverage.
• Uninsured and underinsured motorist coverage -- reimburses you if the other driver doesn’t have auto insurance, or doesn’t have enough to cover your expenses.
Your auto insurance generally covers you as well as someone driving your car with your permission.
Most states require drivers to carry liability insurance. Liability coverage represents about half of most auto insurance premiums, according to ComparisonMarket.com, an online insurance comparison site.
Some auto lenders also require that owners carry auto insurance, and auto lease companies almost always require anyone who wants to lease a car to carry auto insurance with set levels of minimum coverage.
Several states have no-fault insurance laws, meaning that your auto insurance provider pays for your damages even if another driver is at fault. You can still sue for non-economic damages such as pain and suffering in all of these states.
Regardless of what coverage you get, experts recommend comparison shopping to find the best auto insurance deal for you. Several online sites give you access to multiple insurance quotes. You may be able to get a good deal by buying auto insurance from your homeowners or renters insurance provider

Structured Settlement Payment

What Is a Structured Settlement Payment?Formally recognized by the federal government since 1983, structured settlement payments are specified in voluntary settlement agreements between and injury victims and defendant(s). A settlement payment or annuity comes as the result of a contract between a victim and a defendant whereby the injured victim receives a stream of tax-free settlement payments as an annuity tailored to meet their future needs instead of receiving one lump sum. Once a structured settlement payment agreement is reached, the plaintiff cannot make changes.

Structured settlement payments are used more frequently these days because they offer substantial benefits to all parties involved in the structured settlement agreement. Victims receive tax-free payments and defendants get an end to litigation as the result of reaching a structured settlement agreement

How to Sell Structured Settlement Payments
Many people who receive monthly annuity payments under a settlement agreement do not realize they can sell all or a portion of their stream of annuity payments in exchange for a cash lump sum. Getting paid this money can be a way to help fund the current life needs of your family. Receiving the cash now rather than waiting a period of a year or more for a stream of inflexible payments structured in the future can be a big advantage to some people. Factoring is the name of the process of selling ones legal right to receiving future structured payments in exchange for a the present value of that money. This sale becomes a legal contract with the settlement company.

Companies now offer to pay for your rights to receive future annuity payments under structured agreements. The settlement companies offer annuitants the benefit of direct access to cash.

student loan consolidation interest rate

The interest rates for federal student loan consolidations are based on the weighted average of student loan interest rates. Federal Stafford loans disbursed between July 1, 2006 and June 30, 2008 have an interest rate of 6.8%*. Stafford loans disbursed after July 1, 2008 have a rate of 6.0%.
Federal student loans will have different rates depending on type and disbursement dates. For example, rates for Stafford loan disbursed before July 1, 2006 will remain variable until consolidated. Visit StaffordLoan.com or ParentPLUSLoan.com for more details on federal student loan interest rates.

Private Student Loan Consolidation Rates
Private student loan consolidation interest rates are variable, based on either the LIBOR (London Interbank Offered Rate) or the Prime rate, plus a margin for borrower and/or co-signer credit.
Origination fees can range between 1% and 5% depending upon your individual credit or the credit of a co-signer. Any fees that associated with the loan are capitalized (added to the loan) typically at the time repayment begins, which increases the amount borrowed but avoids any out-of-pocket expenses at loan closing.
View interest rate example for graduate private loan consolidation.

Free Non-Student Loan Debt Consultation
Do you have more debt outside of student loans? Please request a free debt consultation today. Consolidate your debt into one lower payment, avoid bankruptcy, and be debt free in as little as 12-48 months.

Houston Criminal Defense Lawyer

Houston Criminal Defense Attorney John T. Floyd, Federal Criminal Lawyer: A Premier Criminal Defense Lawyer Defending Individuals and Businesses Accused of Serious Crimes in Houston, Throughout Texas and in Federal Court Across the United States. John T. Floyd is one of Houston’s top criminal defense lawyers with an unblemished reputation for providing faithful and dedicated representation to his clients. He has committed his entire professional career, as a criminal defense attorney to providing the best possible criminal defense representation to clients not only in Houston but throughout the State of Texas and in federal courts nationwide. Houston Criminal Attorney John Floyd has been rated as among the best and brightest attorneys practicing criminal law and has been recognized as one of huston’s top lawyers for the people (2008,2009), Top lawyers; criminal defense (2008,2009) and has earned a “Superb” rating, scoring 10/10, from "Houston lawyer John Thomas Floyd III - profile with ratings, reviews, bar disciplinary sanctions, law school, and legal awards. John Thomas Floyd III is a licensed attorney in Texas” He has appeared on national television and radio programs as an expert on criminal law related issues and has been quoted in newspapers and other news outlets throughout the country. John T. Floyd is not a former prosecutor turned criminal defense attorney. He has never been a prosecutor. He began his legal career in 1994 as a criminal defense attorney and he has built a practice devoted exclusively to criminal defense work. The John T. Floyd Law Firm has worked hard to create, and maintain, a reputation for professional excellence through its successful criminal defense of individuals and businesses accused of committing serious crimes in all state jurisdictions throughout Texas and federal courts throughout the country. As a criminal defense law firm, the John T. Floyd Law Firm understands the value of pre-trial investigation, pre-trial motions practice, and criminal defense trial preparation. He has qualified legal investigators and a senior paralegal staff under his direction and supervision to bring together the most comprehensive, detailed and competent research possible. The John T. Floyd Law Firm offers client’s the individual attention and personal touch of a high end boutique criminal defense firm along with significant contacts throughout the state and country to assemble a serious criminal defense team that any government prosecutor would find formidable. The criminal defense attorneys in the John T. Floyd Law Firm take nothing for granted. Every possible detail is investigated, legally researched, and analyzed by Mr. Floyd and his staff before a specific criminal defense trial strategy is developed for the particular needs of the criminal case. John T. Floyd believes that criminal defense attorneys are the cornerstone of the legal profession. Individuals and businesses accused of criminal wrongdoing have their very lives, businesses, and families at stake and deserve the best possible criminal defense. A false allegation, mistaken identification, botched or fabricated forensic analysis, or prosecutorial misconduct involving the use of perjured testimony or the suppression of favorable or mitigating evidence can very easily lead to innocent individuals and businesses being wrongfully convicted. Scores of DNA exonerations across the country exemplify this tragic reality. As a criminal defense attorney, John T. Floyd is a criminal defense lawyer committed to making sure that this tragedy is not inflicted upon his clients. State and Federal prosecutors have unlimited prosecutorial resources at their disposal. This is particularly true in the federal courts in Houston, Texas. Federal criminal defense attorneys in Houston, Texas must be prepared to devote their best skills, ingenuity, experience and cutting edge technology to achieve the same level of resources toward the defense of their clients. John T. Floyd is a Houston federal criminal attorney prepared to put forth whatever legal resources are necessary to bring about a favorable outcome for his clients. He is a Houston federal criminal lawyer who understands the awesome powers of the federal government when it targets individuals and businesses for prosecution and he is prepared to defend his clients against such force.

Copper Repiping

Copper repiping is a process of refitting existing pipes in a dwelling or business. Most structures built 25 or more years ago were fitted with iron pipes coated with zinc, normally called galvanized pipes. As the galvanized pipes age, the zinc lining tends to erode allowing rust to form. Once galvanized pipes begin to deteriorate, they need to be replaced. Most people prefer to replace galvanized pipes with copper pipes, in a process referred to as copper repiping.
A water system is composed of two measurable parts: pressure and volume. The pressure is measured as pounds per square inch (p.s.i.). Water pressure represents the force with which the water passes through the pipes and out of your faucets. Water volume represents the amount of water that can flow through your pipes and out through the faucets in a given period of time.
Homeowners usually decide to initiate copper repiping when they begin to see a dramatic drop in water pressure. Decreased water pressure is often very annoying; washing machines fill up more slowly, and garden hoses have a much weaker spray. Perhaps the most evident result of low water pressure is in the shower - instead of a forceful stream, the bather only experiences a dissatisfying trickle of water.
Other ways you know it is time for copper repiping is when the tap water appears discolored due to rust, when a foul odor comes from the tap, or when pipes begin to leak. Plumbers can come into the home and test to see if the problems are being caused by eroding pipes, and make recommendations whether it is time for copper repiping.
Copper is the preferred material for interior pipes because it is lightweight, safe and durable, and does not rust. Because it is also flexible, meaning that plumbers can easily bend and form it within existing walls, it is ideal for repiping.

Give Blood Pressure Drugs to All

Blood-pressure-lowering drugs should be offered to everyone, regardless of their blood pressure level, as a safeguard against coronary heart disease and stroke, researchers who conducted a meta-analysis of 147 randomized trials (comprising 958,000 people) conclude in the May 19 issue of BMJ. “Guidelines on the use of blood-pressure-lowering drugs can be simplified so that drugs are offered to people with all levels of blood pressure,” write Drs Malcolm R Law and Nicholas Wald (Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine, Queen Mary University of London, UK). “Our results indicate the importance of lowering blood pressure in everyone over a certain age, rather than measuring it in everyone and treating it in some.” “Whatever your blood pressure, you benefit from lowering it further,” Law told heartwire . “Everyone benefits from taking blood-pressure-lowering drugs. There is no one who does not benefit because their blood pressure is so-called normal.”
Six years ago, Law and Wald advocated the use of a polypill--containing a statin, three blood-pressure-lowering drugs (each at half the standard dose), folic acid, and aspirin--which they maintained could prevent heart attacks and stroke if taken by everyone 55 years and older and by everyone with existing cardiovascular disease.
In the current meta-analysis, which included people aged 60 to 69, they singled out blood-pressure-lowering drugs to determine the quantitative efficacy of different classes of antihypertensive agents in preventing coronary heart disease (CHD) and stroke. They also sought to determine who should receive treatment.
All Antihypertensives Prevent CHD and Stroke
Overall, the results of the meta-analysis showed that in people aged 60 to 69 with a diastolic blood pressure before treatment of 90 mm Hg or a systolic blood pressure of 150 mm Hg, three drugs at half standard dose in combination (as in the polypill) reduced the risk of CHD by approximately 46% and of stroke by 62%. However, when used individually, a single antihypertensive agent at standard dose had about half this effect.
The five main classes of blood-pressure-lowering drugs--thiazides, beta blockers, angiotensin-converting-enzyme inhibitors, angiotensin-receptor blockers, and calcium-channel blockers--were similarly effective in preventing CHD events and strokes, with the exception of calcium-channel blockers, which had a greater preventive effect on stroke than the other four agents (relative risk, 0.92; 95% confidence interval, 0.85 to 0.98).
People with and without cardiovascular disease derived equal benefit, with similar percentage reductions in CHD events and stroke, and regardless of what their blood pressure was before treatment. Even patients with blood pressures considered to be low--110 mm Hg systolic and 70 mm Hg diastolic--showed fewer CHD events and a reduced incidence of stroke when taking an antihypertensive.
Law and Wald also report that calcium-channel blockers reduced the incidence of heart failure by 19%, and that the other antihypertensive agents reduced heart failure by 24%.
In an accompanying editorial, Dr Richard McManus (University of Birmingham, UK) and Dr Jonathan Mant (University of Cambridge, UK) write that the findings of Law and Wald will contribute to debate on the management of hypertension in several areas. “Taken at face value, these findings provide tacit support for the use of a ‘polypill’ to lower the risk of cardiovascular disease in people likely to be at high risk (such as all people over the age of 55) without first checking their blood pressure.”
In a comment to heartwire , McManus added that he believes that the findings reinforce the view that treatment to lower blood pressure should be offered on the basis of risk, regardless of blood pressure.
Throwing the Baby Out With the Bath Water
On the other side of the Atlantic, hypertension experts were not so sanguine in their opinion of Law and Wald’s conclusions.
Commenting on this study for heartwire , Dr James Elliott (Rush Medical College, Chicago, IL) said he took issue with the authors’ suggestion that the measuring of blood pressure was unnecessary.
“Professors Wald and Law made the revolutionary comment some years ago that we should abandon blood pressure and simply treat everyone at high CVD risk with their magic polypill, which they claimed reduced heart disease and stroke by 90%.This meta-analysis is an unusual compilation of data that supports that hypothesis.”
Abandoning blood pressure measuring is like throwing the baby out with the bath water, Elliott said.
Elliott also took issue with the meta-analysis, which he called “old-fashioned.”
“I think Wald and Law have become the ultimate lumpers. They have included the 37 studies where beta blockers were used against placebo in people with heart attacks, and they have lumped those in with all the other kinds of therapies that we use to lower blood pressure and prevent other events. Nobody, as far as I can remember, has ever included that set of 37 trials in with the other antihypertensive trials because it represents such a different population. They have done the old-fashioned, simple meta-analysis. But there are better ways to understand the data.”
A Meta-Analysis Is Like a Sausage
Adding his opinion, Dr Franz Messerli (St Luke’s-Roosevelt Hospital Center, New York City) said that by including 147 trials in their meta-analysis, the authors had to make numerous assumptions, “some possibly valid, others clearly not.”
Because the “blood pressure fall was not reported in patients with a history of coronary heart disease, they estimated this fall from a meta-analysis of blood pressure trials. This is clearly inappropriate since the fall in blood pressure depends on the pretreatment level, and patients with coronary heart disease who often are hypotensive (particularly post MI) will not respond the same way as do patients with hypertension,” he told heartwire.
It is little surprise that beta blockers now, all of a sudden, look better than in any other review ever done, Messerli added. “Numerous meta-analyses have clearly demonstrated that beta blockers do not reduce the risk of coronary heart disease in hypertension, despite the fact that they lower blood pressure. Thus, despite its appearance of being bigger and better, this study is yet another example of my dictum: A meta-analysis is like a sausage, only God and the butcher know what goes in it and neither would ever eat any.”