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Irregular Heart Rhythm Ups Stroke Risk Soon After Heart Surgery PDF Print E-mail
Title: Irregular Heart Rhythm Ups Stroke Risk Soon After Heart Surgery
Category: Health News
Created: 7/21/2014 12:35:00 PM
Last Editorial Review: 7/22/2014 12:00:00 AM
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Probiotics 'may improve blood pressure' PDF Print E-mail

“Eating probiotics may lower blood pressure,” The Daily Telegraph reports.

Probiotics, so-called “friendly bacteria”, have been found to moderately reduce blood pressure in a new study.

The study is what is known as a systematic review, which is essentially a study of studies. Researchers combined the results of nine randomised controlled trials (regarded as the “gold standard” in evidence-based medicine).

The results suggest that probiotics led to a modest but significant reduction in blood pressure.

The reliability of any systematic review depends on the included studies, and the researchers point out that there were some weaknesses in the studies they included. For example, six of the trials were only conducted on 20 to 40 people. With such a small sample size, any effect on blood pressure could have been the result of chance.

As the lead researcher is quoted as saying in the media, more research is required before doctors can confidently recommend probiotics for high blood pressure control and prevention.

Proven methods to improve blood pressure levels include quitting smoking, sticking to the recommended levels of alcohol consumption, eating a healthy diet (in particular, reducing salt consumption) and taking regular exercise.

 

Where did the story come from?

The study was carried out by researchers from Griffith University and Gold Coast Health, Australia. No source of funding was reported.

The study was published in the peer-reviewed medical journal Hypertension.

The story was accurately reported in the media, though the Daily Express’s claims that eating “a pot a day [could] … help save your life” is probably overstating the findings of the study.

 

What kind of research was this?

This was a systematic review and meta-analysis that aimed to determine the effect of probiotic consumption on blood pressure. Systematic reviews aim to identify all the evidence related to a specific research question and synthesise the findings from individual studies or reports in an unbiased way. Meta-analysis is a mathematical technique for combining the results of individual studies to arrive at one overall measure of the effect of a treatment.

The researchers also aimed to use their results to provide information on the most effective probiotic and dose, and how long probiotics need to be taken.

A systematic review, when performed well, should give the best possible estimate of the true effect of probiotics on blood pressure.

 

What did the research involve?

The researchers searched databases of published literature and trials to identify randomised controlled trials (RCTs) that had given people probiotics and had assessed the effect on blood pressure.

Once they had identified relevant trials, the researchers assessed them to see if they were well-performed and extracted data.

The results of all the trials were then combined to produce a "bottom line" on the effectiveness of probiotics on blood pressure.

 

What were the basic results?

The researchers included nine RCTs with 543 participants in total. Six of the trials had between 20 and 40 participants.

Some trials involved healthy people, others included patients with hypertension (high blood pressure), hypercholesterolemia (high levels of cholesterol in the blood), metabolic syndrome (a combination of diabetes, high blood pressure and obesity) or who were overweight or obese. The species and dose of probiotics used, and how they were given, also varied across the trials.

Trials used either yoghurt, fermented and sour milk, probiotic cheese, encapsulated supplements or rose-hip drinks.

The trials gave people between a single species and three species of probiotic at the same time, and the daily dose of probiotics varied between 109 colony-forming units and 1012 colony-forming units. A colony-forming unit is an estimate of the amount of micro-organisms, usually bacteria or fungi, in a given sample.

The duration of the trials varied from three weeks to nine weeks.  

After combining the results of the trials the researchers found that:

  • Probiotic consumption significantly reduced systolic blood pressure by 3.56 mm Hg compared to control (systolic blood pressure is the "top" number and is the blood pressure in the arteries when the heart beats).
  • Probiotic consumption significantly reduced diastolic blood pressure by 2.38 mm Hg compared to control (diastolic blood pressure is the "bottom" number and is the blood pressure in the arteries between heart beats).

By combining the results of different sub-groups of studies they found that:

  • Using dairy products as the source of probiotics resulted in significant reductions in systolic and diastolic blood pressure, whereas using other sources of probiotics did not.
  • Using multiple species of probiotics resulted in significant reductions in systolic and diastolic blood pressure, whereas using a single species did not.
  • Using a dose of at least 1011 colony-forming units per day resulted in significant reductions in systolic and diastolic blood pressure, whereas using lower doses did not.
  • Taking probiotics for at least eight weeks resulted in significant reductions in systolic and diastolic blood pressure, whereas taking probiotics for shorter periods did not.
  • People who had blood pressure of 130/85 mm Hg (higher than ideal but still normal) or higher had significant improvements in diastolic blood pressure but people with blood pressure less than 130/85 mm Hg did not.

 

How did the researchers interpret the results?

The researchers concluded that their results suggest consuming probiotics may improve blood pressure by a modest degree, and that this effect may be greater if blood pressure is high to begin with, multiple species of probiotics are consumed, probiotics are taken for eight weeks or longer, and if each dose contains at least 1011 colony-forming units.

They go on to say that “the reduction [in blood pressure] reported in this meta-analysis is modest; however, even a small reduction of [blood pressure] may have important public health benefits and cardiovascular consequences.”

 

Conclusion

This systematic review and meta-analysis has found that probiotic consumption results in moderate reductions in blood pressure.

The results of a systematic review depend on the included studies, and the researchers point out that there were some weaknesses in the studies they included. They say that “more randomised, controlled studies with larger sample groups, longer durations and adequate blinding of conditions trials are needed to confirm the effect of different probiotic species and products on BP [blood pressure] and hypertension.”

Analysis of subgroups of studies led the researchers to conclude that blood pressure improvements may be greater among those with elevated blood pressure, when the daily dose of probiotics is at least 1011 colony-forming units, when more than one species of probiotic is taken and when probiotics are taken for at least eight weeks.

However, they also point out that these conclusions are based on the results of only a few studies, and the majority of them were very small – six of the trials were only conducted on between 20 and 40 people.

As the lead researcher is quoted as saying in the media, more research is required before doctors can confidently recommend probiotics for high blood pressure control and prevention.

Proven methods to improve blood pressure levels include quitting smoking, sticking to the recommended levels of alcohol consumption, eating a healthy diet (in particular, eating a low salt diet) and taking regular exercise.

Read more about how to improve your blood pressure.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Eating probiotics may lower blood pressure. The Daily Telegraph, July 22 2014

Eating probiotic yoghurt could lower blood pressure and protect against heart disease. Mail Online, July 21 2014

Yoghurt can beat high blood pressure, claims new study. Daily Express, July 22 2014

Links To Science

Khalesi S, Sun J, Buys N, Jayasinghe R. Effect of Probiotics on Blood Pressure - A Systematic Review and Meta-Analysis of Randomized, Controlled Trials. Hypertension. Published online July 21 2014

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Can Bike Riding Up Prostate Cancer Risk? PDF Print E-mail
Title: Can Bike Riding Up Prostate Cancer Risk?
Category: Health News
Created: 7/18/2014 12:35:00 PM
Last Editorial Review: 7/21/2014 12:00:00 AM
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HPV Test Beats Pap Smear in Gauging Cervical Cancer Risk, Study Finds PDF Print E-mail
Title: HPV Test Beats Pap Smear in Gauging Cervical Cancer Risk, Study Finds
Category: Health News
Created: 7/18/2014 4:36:00 PM
Last Editorial Review: 7/21/2014 12:00:00 AM
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Full-Time Job May Disrupt Breast-Feeding Plans PDF Print E-mail
Title: Full-Time Job May Disrupt Breast-Feeding Plans
Category: Health News
Created: 7/18/2014 9:36:00 AM
Last Editorial Review: 7/18/2014 12:00:00 AM
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'More adults should be taking statins,' says NICE PDF Print E-mail

"Doctors have been told to offer cholesterol-lowering statins to millions more people," BBC News reports.

New guidelines from the National Institute for Health and Care Excellence (NICE) recommend lowering the bar for statin use in adults at risk of heart disease. 

NICE suggests up to 8,000 lives could be saved every three years if everyone with a 10% risk of developing cardiovascular disease within the next 10 years is offered one of the widely used cholesterol-lowering medications.

Cardiovascular diseases are diseases affecting the heart and blood vessels, such as heart disease and stroke.

NICE says the evidence clearly shows statins are safe and effective and would be a good use of healthcare resources if given to these people.

The announcement has been met with a variable response, with the Daily Mail saying up to half of all adults could now be eligible for the drugs, and that, "GPs warn of chaos" at being "told to trawl medical records to find at-risk patients".

On the other side of the argument, Professor Baker, director of the Centre for Clinical Practice at NICE, says the new recommendations would not create an additional workload for GPs.

On the NICE website, he said: "Most patients will already be under surveillance by their GPs, so this won't add any additional workload. But you can do the QRISK2 risk assessment yourself. It can be done online or via an app, so it doesn't need to be done by the GP."

You can assess your own risk online using a risk assessment tool based on factors such as smoking history, body mass index (BMI) and family history of heart disease.

The NICE guidelines have now been published, which means they will come into effect in the NHS in England. However, NICE still recommends preventable lifestyle measures, such as losing weight or stopping smoking, are addressed first before starting statin treatment.

Ultimately, the decision to take a statin – even if it is recommended – will always remain a choice that sits with the patient.

 

What are statins?

Statins are usually the first medication of choice to reduce the levels of low-density lipoprotein (LDL, or "bad") cholesterol in the blood.

Cholesterol and other fatty substances can build up and clog the arteries in the heart and elsewhere in the body, leading to cardiovascular diseases. Reducing cholesterol levels helps reduce the risk of cardiovascular events such as heart attack or stroke.

Examples of statin drugs are simvastatin and atorvastatin, which come as tablets. The recommended treatment course is to usually take a tablet once a day for life.

 

What is NICE recommending?

NICE has published an update to its previous clinical guideline on the cardiovascular risk assessment and management of lipids (fats in the blood, which includes cholesterol and triglycerides) in people who either already have cardiovascular disease (such as those who've had a heart attack or stroke), or people who are at risk of developing cardiovascular disease.

The main new recommendations are that:

  • A systematic strategy should be used in general practice to identify people who are likely to be at high risk for developing cardiovascular disease (CVD).
  • People should be prioritised for a full risk assessment if their estimated 10-year risk of CVD is 10% or more (using the QRISK2 assessment tool).
  • Before starting lipid-lowering medications for the prevention of CVD, at least one blood sample should be taken to measure total cholesterol, high-density lipoprotein (HDL, or "good") cholesterol, non-HDL cholesterol, and triglyceride concentrations.
  • In people who have a 10% or greater risk of developing CVD within the next 10 years, the recommended statin to start treatment with is atorvastatin, given at a dose of 20mg daily.
  • In people who already have established CVD (people who have heart disease or have had a stroke), the recommended starting dose of atorvastatin is 80mg daily (unless there are side effects or other contraindications).

For people at risk of developing CVD within the next 10 years, the recommendations to start 20mg atorvastatin applies to adults of all ages, including people over the age of 85 years (in very elderly people, statins may reduce the risk of a non-fatal heart attack). This advice stands unless there are other health-related factors that make statin treatment inappropriate.

NICE does make several important provisions around decisions to start treatment for the prevention of CVD in people considered to be at risk.

These are outlined below.

Patient-doctor discussion

The decision whether to start a statin should be made after an informed discussion between the doctor and patient about the risks and benefits of treatment, taking into account factors such as:

  • possible benefits from lifestyle modifications (measures that could be tried first before starting a statin, such as exercising more, eating a healthier diet and stopping smoking)
  • patient preference
  • other medical illnesses
  • the problems of adding another tablet if the person is already taking a lot of daily medications
  • general frailty and life expectancy

Lifestyle changes

Before starting statin treatment, assessment should be made into other health and lifestyle factors that may need management, including:

  • smoking and alcohol consumption
  • blood pressure
  • BMI
  • diabetes
  • kidney or liver disease

The benefits of optimising all other modifiable lifestyle risk factors (for example, overweight/obesity or smoking) should be discussed, and people offered support for this if needed, such as exercise referral programmes.

Statin treatment may then be considered if lifestyle modifications don't work.

 

What is the rationale for lowering the threshold for the drugs?

Currently, one-third of deaths in the UK are caused by cardiovascular disease, accounting for around 180,000 deaths each year.

Cardiovascular disease is well known to have a significant burden of disability. It is believed £8 billion of healthcare resources are tied up in the disease.

Professor Mark Baker, director of the Centre for Clinical Practice at NICE, says: "Doctors have been giving statins to 'well people' since NICE first produced guidance on this in 2006. We are now recommending the threshold is reduced further.

"The overwhelming body of evidence supports their use, even in people at low risk of CVD. The effectiveness of these medicines is now well proven and their cost has fallen. The weight of evidence clearly shows statins are safe and cost effective for use in people with a 10% risk of CVD over 10 years."

Dr Anthony Wierzbicki, from Guy's and St Thomas' Hospitals, London, and chair of the Guideline Development Group, also commented on the new guidance: "We've been able to simplify the guideline so it's now much easier for patients to be assessed and for GPs and nurses to make sense of the results. There is greater clarity, a simpler framework, and a systematic way of identifying people who could benefit from treatment.

"We've got the best evidence base, huge numbers, and the biggest set of clinical trials ever done. Other areas of medicine would give their teeth for this evidence, it's that good. Statins work, they are very cheap, and are becoming considerably cheaper as they come off-patent, which, in a cost-limited health service, is a big consideration.

"That enables us to actually say that we should treat people with heart disease a lot more intensively because we know that will prevent further events. In people with diabetes or kidney disease, giving a statin will reduce heart attacks and strokes. For people at risk of heart disease, if lifestyle measures fail, we have a second option of giving them a statin if they want and require it."

 

Are there any risks or side effects with statins?

Statins are fairly safe drugs, though there are a range of possible side effects and groups of people who should use them with caution. This includes people with an underactive thyroid, kidney disease and liver disease. Women should also not take statins while pregnant or breastfeeding.

Possible side effects include headaches and dizziness, sleep disturbances, fatigue, tummy disturbances, altered sensation, and sensitivity reactions such as rash or itching.

Very rarely, statins have been associated with the risk of having a toxic effect on the muscles, causing muscle pain and weakness, and even a serious condition called rhabdomyolysis, where the muscle fibres start to break down.

However, the risks and benefits would be discussed and taken into account for any individual before a statin is prescribed, including their personal and family medical history.

 

How has the announcement been received by the media?

As the BBC News headline indicates, NICE's decision has been met with controversy. 

Professor Mark Baker, the director of the Centre for Clinical Practice at NICE is quoted as saying: "Prevention is better than cure. One of the mainstays of modern medicine is to use treatments to prevent bad things happening in the future. It's why we use vaccines and immunisation to prevent infectious disease, it's why we use drugs to lower blood pressure to prevent heart attacks, strokes, and kidney disease, and it's why we're using statins now."

Meanwhile, in opposing camps there is debate about "medicalising" a nation and encouraging people to just pop a pill rather than following a healthy lifestyle.

The British Medical Association's General Practitioner Committee is quoted as saying: "There is insufficient evidence of significant overall benefit to low-risk individuals to allow GPs to have confidence in the recommendation. The measure would distort health spending priorities and disadvantage other patients."

However, as quoted in the Daily Mail, Professor Baker responded: "It is ludicrous to suggest that we are overmedicalising the population when the whole point of using modern, safe and effective drugs in an economic way is to prevent bad things happening in the future."

Dr Chaand Nagpaul, chair of the British Medical Association's GP committee, feels NICE has not taken into account the additional pressures they'll be placing on GPs. "In making their decision, NICE has failed to take the current pressures on general practice into account, and the further impact this will have on already overstretched GPs and those patients requiring treatment for other illnesses."

Despite the extensive debate and opposition, as BBC News also highlights, the 10% threshold for statin treatment is comparable to that already used in other European countries.

As the president of the Academy of Medical Sciences, Professor Sir John Tooke, points out on the BBC News website: "Whether or not someone takes drugs to diminish their risk is a matter of personal choice, but it must be informed by accurate information on the balance of risk and benefit in their particular case. The weight of evidence suggests statins are effective, affordable and have an acceptable risk-benefit profile."

 

Conclusion

Despite somewhat hysterical media coverage to the contrary ("millions more to be given statins," according to the Daily Express), nobody will be forced to take statins.

If your GP does recommend statins, you should ask them to explain the benefits and risks for you personally of starting statin treatment. You may want to find out more about statins before making up your mind – the NHS Choices Health A-Z information on statins is a good place to start.

If you do experience troublesome side effects while taking statins, contact your GP or the doctor in charge of your care. It could be the case that adjusting your dosage or switching to a different type of statin could help relieve any side effects.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Statins: Millions more to get drugs in controversial plans. BBC News, July 18 2014

Prescribing statins more widely 'could avert tragedy', new medical guidelines suggest. The Independent, July 18 2014

NHS medicines watchdog lowers bar for statins prescriptions. The Guardian, July 18 2014

Forty per cent of adults advised to take statins under new NHS guidance. The Daily Telegraph, July 18 2014

GPs warn of chaos over bid to offer statins to 17m to prevent heart disease: Doctors being told to trawl medical records to find at-risk patients. Daily Mail, July 18 2014

Statins to be offered to '40% of adult population'. ITV News, July 18 2014

Give statins to 17m says NHS watchdog. Daily Express, July 18 2014

Links To Science

National Institute for Health and Care Excellence. Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. July 2014

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