PROBLEMS IN THE EVIDENCE OF EVIDENCE BASED MEDICINE.

The oft repeated statement that the incidence of coronary artery disease is going up exponentially in the immigrant population (as also in others) needs further scrutiny. Is it just a statistical anomaly or a real increase needs to be seen?1 In our reductionist bio-medical model of diseases we use coronary artery blocks and coronary artery disease synonymously. Many people could have blocks in the epicardial vessels without any evidence of coronary artery disease; elegantly shown in the studies of Vietnam and Korean War casualties!2 Many of those that have innocent blocks could be provoked to have coronary artery disease by our precocious labeling them. Evidence based medicine can not assess the gravity of frightening patients about fatal diseases and doctors predicting their unpredictable future course. Many of these youngsters could eventually suffer the ravages of the Ulysses syndrome.3

“Evidence-based medicine (EBM) has been defined as the "conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research." More specifically, EBM reflects a concerted effort to systematically retrieve and synthesize data, make the data available to physicians, and incorporate it into practice. “Intuition and individual clinical experience are deemphasized and decision-making based on evidence is stressed. Although there have been some concerns about whether there is sufficient evidence to guide many of our clinical decisions, about what represents the best available evidence, and about the authoritarian voices of the EBM movement, it should be our goal to make the most informed medical decisions on behalf of patients.” writes Howard Bauchner.4

If one were to take a holistic view of coronary artery disease incidence one has to give equal weightage to the environment in which the immigrants are placed-their acculturation. Going to a foreign land in search of greener pastures, in itself, has the inbuilt anxiety factor that has a very great causal effect on their health status. With newer studies showing the mind as the major player in the causation of coronary artery disease, one wonders why the authors are still harping only on the time honored “risk factor hypotheses” of fat, blood pressure, diabetes etc.5 The latter could all be the genetic clusters in such individuals rather than being the cause of one another! The conventional fat hypothesis has led to the burgeoning business in anti-cholesterol drugs that seems to have only changed the label in the death certificates without changing the date!6, 7, 8 Too much drugging for lowering patient’s blood sugar and blood pressure have both been counterproductive to say the least.9, 10

The family background of the immigrants and their economic status could also be contributing to the incidence of coronary disease. Coronary artery disease also follows the rule that poverty is the mother of most ills. Barker’s hypothesis could be working in those immigrants that were born to abject poverty. Therefore, if future studies are being planned to study the reasons why the immigrants have precocious coronary disease the above mentioned suggestions could be incorporated there to make it more evidence based and authentic. We seem to be absolutely certain about the risk factors in coronary disease as we know very little about its causation.11 “Man is absolutely certain when he knows very little, with knowledge doubts increase” said Goethe.

Recent evidence points to the role of life style modifications with a special stress on tranquility of mind as the best insurance against precocious coronary disease as also in the management of established CAD. That needs to be incorporated in the evidence based management strategies of CAD.12, 13, 14



References:

1) Stehbens WE. An appraisal of the epidemic rise of coronary heart disease and its decline. The Lancet 1987;182: 399-405.

2) Enos WF, Holmes RH, Beyer J. Coronary artery blocks among US soldiers killed in action in Korea. JAMA 1953; 152: 1090-1093.

3) Rang M. The Ulysses Syndrome, Can Med Assn J 1972; 106: 122-123.

4) Bauchner H. Cumulative meta-analysis of therapeutic trials for myocardial infarction. N Engl J Med 1992; 327: 248-254.

5) Rozanski A, Blurnenthal JA, Davidson KW et al. The epidemiology, patho-physiology and management of heart diseases-milestones in cardiac prevention. J Am Coll Cardiol 2005; 45: 637-651.

6) Hegde BM. Need for a change in medical paradigm. Proc. Royal Coll Physi. Edinb. 1993; 23: 9-12.

7) Jacobs D, Balckburn H, Higgins M et. al. Report of a conference on low cholesterol and mortality association. Circulation 1992; 86: 1046-60.

8) Sheppard J, Cobbe SM, Islers CG et. al. Prevention of Coronary artery disease. N. Engl.J Med 1995; 333: 1301-1307.

9) Dunder K, Lind L, Zethelius B, et. al. Increase in blood glucose concentration during antihypertensive treatment as a predictor of myocardial infarct. BMJ 2003; 326: 681.

10) McCormack J, Greenhalgh T. Seeing what you want to see in research-The UPSPD study. BMJ 2000; 320: 1720-1723.

11) Superko HR, Wood PD,Haskell WL. Coronary heart disease and risk factor modification: is there a threshold? Am J Med 1985: 78 826-38.

12) Blumenthal, J, M. Babyak, et al. "Usefulness of psychosocial treatment of mental stress-induced myocardial ischemia in men." American Journal of Cardiology, 2002, Vol. 89. 164-168.

13) Ornish, D., Scherwitz, L.W., et al. "Intensive Lifestyle Changes for Reversal of Coronary Heart Disease." Journal of the American Medical Association (JAMA), 1998, Vol. 280. 2001-2007

14) Brody, Jane and Denise Grady, The New York Times Guide to Alternative Health. New York: New York Times Co., 2001. 203-244.

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