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  • High Blood Pressure: It’s A Symptom, Not A Disease, Stupid! By Dr. Malcolm Kendrick

    Posted by .(JavaScript must be enabled to view this email address)
    Wednesday, January 27, 2010 12:38 pm Email this article
    Let’s suppose that one day you went to the doctor and she decided to take your temperature, just to see what it was. To your surprise it was two degrees higher than normal. As we all know, a high temperature is associated with a higher than normal level of mortality, so the doctor decided to use a drug to get your temperature down, along with advice to wear less clothes and take cold baths.

    Time passes and you have been on this drug for five years. The baths and chilly walks are getting to be a bit of a pain. On the bright side, at least the temperature is back to normal.

    I think you would agree that such a scenario is, quite frankly, nuts.

    (This article was written by Malcolm Kendrick, MD, author of the wonderful, eye-opening, paradigm-shifting book The Great Cholesterol Con: The Truth About What Really Causes Heart Disease and How to Avoid It .) Treating High Blood Pressure

    The logic (or illogic) of treating high blood pressure

    Yet, every day, thousands of people are found to have high blood pressure, and put on blood pressure lowering drugs on pretty much the same basis. The logic, after all, is the same.

    1. People with high blood pressure are more likely to die from coronary heart disease (CHD).
    2. Therefore a high blood pressure causes CHD.
    3. Therefore if you lower the blood pressure you will reduce the rate of CHD.
    4. So, take a blood pressure lowering drug for the rest of your life.

    I suppose that most people believe that it must have been proven by now that blood pressure lowering does reduce the rate of CHD, rendering the example of a high temperature somewhat pointless. Well, I am going to quote you quite a long passage from the European Heart Journal, issue 20, October 2000. Please read it carefully, for it is actually quite stunning.


    Randomized trials have NOT proved lowering blood pressure is beneficial

    Randomized trials have NOT proved that lowering blood pressure is beneficial notes UCLA statistician, Sid Port

    “It is widely believed that randomised trials have proved that lowering blood pressure is beneficial. Actually, that is not true. All antihypertensive drugs have profound effects on the cardiovascular system, aside from their haemodynamic (blood pressure lowering) effect. How much, if any, of the observed risk reduction can be ascribed to the reduction in pressure and how much to the direct action of the drug on the cardiovascular system? Motivated by the belief in the linear relationship of risk to pressure, many automatically attribute the risk reduction to the pressure reduction, ignoring the direct action of the drugs on the target outcomes. But results of a multitude of clinical trials make it clear that such a simplistic view cannot be true. In fact, evidence is mounting (especially from the newer trials) that it is the direct effects that are producing most, if not all, or the benefit and that the accompanying blood pressure reduction may be just an inconsequential side effect.”
    —Port S, Garfinkel A, Boyle N. There is a non-linear relationship between mortality and blood pressure. Eur Heart J. 2000 Oct, 21(20):1635-38.


    No evidence that lowering blood pressure lowers CHD

    No evidence whatsoever that lowering blood pressure has any effect on CHD

    In short, there is no evidence whatsoever that lowering blood pressure has any effect on CHD. As they authors of the paper further state:

    “ALLHAT (A major blood pressure lowering trial) showed a dramatic difference between alpha blockers and diuretics, with essentially no difference in blood pressure between the treatment and control groups.”


    Does Hypertension Cause CHD?

    The hypothesis that blood pressure causes CHD is nonsense

    Quelle surprise? Not really, after all, the underlying hypothesis that blood pressure causes CHD was always nonsense. After all, how could a high blood pressure make atherosclerotic plaques form? Well, you can create a convoluted argument involving endothelial damage, but you would struggle to create a clear cut case.


    Plaques may force the heart to pump harder, increasing blood pressure

    Plaques may force the heart to pump harder, increasing blood pressure

    On the other hand, it is very much more simple to see how an atherosclerotic plaque, by narrowing an artery supplying blood to a vital organ, can trigger the heart to pump harder, thus overcoming the narrowing in the artery by increasing the blood pressure.


    What is High Blood Pressure and What Causes It?

    In about 10% of cases, there is clear cause; in 90% of cases, there is no clear cause

    Perhaps it is time for a rewind. What is a high blood pressure, and what could cause it? In about ten per cent of cases there is a clearly established cause for high blood pressure. Conditions such as renal artery stenosis, or hyperthyroidism, or kidney problems. If these are treated, the blood pressure drops back to normal.


    Essential Hypertension is Really ‘Raised Blood Pressure of No Known Cause’

    The name Essential Hypertension makes it sound like a real disease rather than a symptomless medical sign

    However, in about ninety per cent of cases when the blood pressure is raised, no cause can be found. At which point the medical profession, rather than using the somewhat pathetic sounding term ‘Raised blood pressure of no known cause,’ decided to rename the condition Essential Hypertension. You’ve got to admit, this sounds a great deal more scientific and ‘disease like.’ In fact it sounds so impressive that Essential Hypertension has managed the transformation from ‘symptomless medical sign’ to a real disease, one that needs to be treated.


    What Causes Blood Pressure To Rise?

    What causes the blood pressure to rise?

    Let’s examine the logic in use here. One day, for no known reason, your body decides that the blood pressure needs to be raised. So your heart pumps harder, or your arteries decide to contract, or both. This has the desired effect of raising the blood pressure to a point where it can cause damage. It can lead to strokes, heart failure, kidney failure, etc.

    Undeterred by the damage that this raised blood pressure is causing, the body continues for day after day, month after month, year after year, to keep the pressure up. Eventually your heart can’t carry on any more, so it starts to pack in, you develop heart failure, and within about five years you are dead.

    There is just one teensy little thing missing from this model. A cause. Why does the pressure suddenly rise? One thing is for sure, the body does nothing without a cause, especially if the effect is to damage health. So we need to ask a deeper level question. What could cause the blood pressure to rise?

    In order to understand this, you need only to the grasp the exceedingly simple concept that the pressure of liquid flowing through a pipe is a function of two variables. The first variable is the rate of flow of the liquid; the second is the diameter of the pipe. If you want to increase the pressure you must pump more fluid, or narrow the pipe.


    There Are Only Two Ways To Increase Blood Pressure

    For blood pressure to go up, either the heart is pumping harder or the arteries have narrowed

    Therefore, if your blood pressure goes up, for no known reason, one of two basic things is happening.

    1. The heart is pumping harder.
    2. The diameter of the arteries has narrowed (causing the heart to pump harder to keep the blood flow the same).


    CHD Is a Probable Cause of High Blood Pressure

    CHD is cause of high blood pressure, NOT the other way around

    Things that make your heart pump harder would include: anxiety, exercise, stimulants e.g. coffee. Things that narrow your arteries would be……? Dum de dum, let me think. Oh yes. An atherosclerotic plaque (the underlying cause of CHD) would narrow an artery. Therefore, a probable cause of high blood pressure is the presence of CHD.


    Medicine Is Grabbing the Wrong End of the Stick

    Lowering blood pressure does NOT reduce heart attacks

    Thus, ergo etc. a high blood pressure is not a cause of CHD. Instead CHD is a cause of high blood pressure. So yet again gentle reader, as with raised cholesterol levels and CHD, we see another rather grisly example of the medical profession grasping the wrong end of the stick and desperately trying to cure a disease (CHD) by sweeping a symptom of that disease (high blood pressure) under the carpet. No big surprise, it doesn’t actually work.

    Does this all seem incredibly basic? It should, because it is. So, whilst blood pressure lowering may have some effect on preventing strokes, heart failure and other pressure related problems, it has no effect on reducing death from heart attacks. After all, how could it?


    Most Scientist Never Read the Papers They Reference

    Most scientist never read the papers they reference, they just copy and paste them

    Some of you may have seen research reported in the

    New Scientist magazine which established quite clearly that most scientific researchers don’t bother to read the full papers that they use for references. In fact, most of them just copy and paste the list of references used in other papers.

    This may seem a somewhat arcane issue, removed at two steps from real life. I can sense a collective ‘so what?’ resonating round the world on this issue.

    But please pay attention, because this fact is VITALLY IMPORTANT!

    And it explains much about the treatment paradigm for high blood pressure.

    Measurements Are Imprecise

    Blood pressure measurements change

    In medical science, many measurements are imprecise. A blood pressure taken at ten in the morning may have changed five minutes later. The doctor may have put the blood pressure cuff on in a slightly different way, whatever. So, when you start drawing a graph of blood pressure measurements taken over time vs. the rate of death, in different groups of people, it does not have precise cut-off points. It may look more like someone has fired blunderbuss at a piece of graph paper.

    However, if you are really clever and understand mathematics and calculus, and suchlike, you can draw a perfect line through that mass of dots. This can be called a ‘linear logistic model.’ (My line is just a random guess by the way)

    However, to quote the European Heart Journal:

    “Before one can have confidence that the linearity correctly reflects the behaviour of the data, and is not just an artefact of the model, it is necessary to carefully examine the data in relation to the proposed model.”

    In plain English, stop guessing. Although guessing does look a lot more impressive when you use terms such as Cox model and double-tailed chi-squared, etc. which no one understands.

    So, what does this all have to do with the price of beans?

    I have two strands to my discussion so far. Strand one: most researchers never bother to read the papers they quote; at most they manage to read the abstract. Stand two: statistical models used to look at blood pressure vs. mortality are all based on the supposition that ‘the relation of blood pressure to risk of death is continuous graded and strong, and there is no evidence of a threshold.’


    The Framingham Study (1968) Started the Belief—‘The Lower, the Better’

    Almost no one has questioned this

    Now, where did this supposition first come from? Our old friend Framingham, the world’s longest and most detailed study of the relationship between various ‘risk factors’ and death from heart disease. Researchers looking at the Framingham data started the ‘linear and continuous’ ball rolling, and, ever since, everyone has decided to use the same methodology. A statistical methodology which implies that the lower the blood pressure the better, and there is no lower limit.


    This Error Has Been Repeated and Repeated

    The belief that ‘The Lower, the Better’ has been repeated by many papers, so everyone assumes it’s true

    No one questions this methodology; in fact it has been quoted in so many papers over the years that it would appear to have been proven beyond the shadow of a doubt. But of course, the reason why it is now quoted so often is that paper after paper has quoted from other papers that have all shown this linear regressive model to be true. A process of error reinforcing error.

    To give a more concrete example of how this happens. I write a paper which states that ‘the relation of blood pressure to risk of death is continuous graded and strong.’ Someone else comes along and quotes that paper, without bothering to look at the methodology or results. So now I have two papers making the same statement.

    Then, along comes researcher B, who is looking for papers on blood pressure and mortality. He sees two papers with the same self-reinforcing statement on it, and quotes them. Now I have three papers making the same statement. How long before there are one hundred, two hundred, a thousand papers?


    Mis-Citations Can Occur Many Thousands Of Times

    Mis-citations can occur many thousands of times notes the New Scientist

    You think this number may be an exaggeration, but Simkin and Roychowdury (who looked at the issue of misreporting) found that mis-citations can occur many thousands of times. To quote the New Scientist article again:

    “To find out how common this (misreporting) is, Simkin and Roychowdhury looked at citation data for a famous 1973 paper on the structure of two-dimensional crystals. They found it had been cited in other papers 4300 times.


    Misconceptions Spread Like Weeds

    When misconceptions take root, they spread like weeds notes the New Scientist 

    And the errors this leads to are not specific to two-dimensional crystals:

    “The problem is not specific to this paper, the researchers say. Similar patterns of errors cropped up in a dozen other high-profile papers they studied. The trouble is that researchers trust other scientists to repeat the key message of a paper correctly. This means that when misconceptions take root, they spread like weeds.”


    They Have Used the WRONG Statistical Model For High Blood Pressure Since 1968

    They have been using the WRONG statistical model for high blood pressure since 1968

    It should be clear by now, where I am heading.

    Someone, somewhere, decided that there is a continuous linear relationship between death and blood pressure. They used a statistical method to establish this, and ever since everyone has used the same model. So there are now thousands and thousands of papers out there ‘proving’ this paradigm to be true. In fact, if you wrote a paper on the treatment of high blood pressure using another model it would almost certainly be rejected on the basis that the linear relationship model was the established, and correct, model, so yours must be wrong.

    There is just one teensy, weensy, little problem here. When you actually decide to look at the data - it disproves the model.

    “Shockingly we have found that the Framingham data in no way supported the current paradigm to which they gave birth. In fact, these data actually statistically reject the linear model. This fact has major consequences. Statistical theory now tells us that the paradigm MUST be false...”
    —Port S, Garfinkel A, Boyle N. There is a non-linear relationship between mortality and blood pressure. Eur Heart J. 2000 Oct, 21(20):1635-38.

    I didn’t add the italics or capital letters. The Authors put them in - the paradigm MUST be false. Normally, in clinical papers, people state things very calmly, e.g. ‘the data suggests an association between.’ So to see a statement such as the paradigm MUST be false is very strong stuff.

    So what is really being stated here that is so important?


    Analogy to High Altitudes

    At 16,000 feet you will die, but that does not mean that lower altitudes are harmful

    I will use an analogy to try to make the point. If you chose to live in the Himalayas you may find yourself twelve thousand feet above sea level. Most people can cope with this height, and it has very little impact on your health or life expectancy. Go up a few thousand feet and everyone dies. The exact ‘death zone’ height varies from person to person.

    The fact that you die at sixteen thousand feet, however, does not mean that any altitude above sea level is harmful. What it means is that, at a certain level, your body cannot cope any more and the systems start to break down.

    Yet, with blood pressure, any rise represents a risk - according to the linear model. There is no ‘death zone’ no cut-off point. According to this logic, even if you have a ‘normal’ blood pressure, it would be better if you could get it lower. And believe me, papers have been written stating this.


    Having A Cutoff Point for High Blood Pressure Makes More Sense

    Having a cutoff point for high blood pressure, above which causes problems, makes more sense

    But, anyone with half a brain can see that a model with a ‘cut point’ is much more likely to be correct. Is it really likely that a 5-15mmHg rise in blood pressure will cause problems? According to the linear model, the answer is yes. But, as we have seen, the data doesn’t actually support a linear model, and logic would also dictate that at a certain point - which has, in reality, never been defined - a raised blood pressure creates problems. Below that point it may be a bit high, but frankly it’s nothing to worry about.


    Cutoff for Systolic Blood Pressure Probably 160-180

    Medicine mistakenly suggests that everyone should try to get blood pressure lower

    What is that point…. I don’t know. But I would guess it is something like a systolic of 160 - 180. However, the medical profession, with its ever present desire to squeeze all patients into a little box called ‘normal’ is inexorably bringing down the level at which treatment is needed. I have seen calls to get everyone to a level of 120/70 (the level considered ‘normal’). The WHO has set the limit at 130/85. Already in diabetes the recommended level is 120/85.


    The False Paradigm for High Blood Pressure

    The false paradigm for high blood pressure has been repeated so often, everyone believes it

    Why are they trying to achieve this? On the basis of a model made up years ago which, due to sloppy research, has become accepted fact. On the basis of a model which, if you examine it properly, MUST be wrong. Try explaining this to your local, friendly doctor, you will get the same reaction that I always do. ‘Don’t talk rubbish, it has been proved that you should lower the blood pressure as much as possible.’



    Article Previous Published on THINCS.org

    This article was previously published on THINCS.org

    This article was previously published on THINCS.org (The International Network of Cholesterol Skeptics).

    I republished the article here with Dr. Kendrick’s permission.


    Malcolm Kendrick’s Contact Info

    Malcolm Kendrick’s Email Address—.(JavaScript must be enabled to view this email address)

    Dr. Malcolm Kendrick can be reached at .(JavaScript must be enabled to view this email address).

    Malcolm Kendrick, MD is the author of the wonderful, eye-opening, paradigm-shifting book book The Great Cholesterol Con: The Truth About What Really Causes Heart Disease and How to Avoid It .)


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