First Do No Harm

1
First Do No Harm

• Family Medicine Unit
• http//www.hku.hk/fmunit/

2
Madam Ip

• A 71 year-old retired restaurant worker
  consulted in September, 2001 requesting screening
  for hypercholesterolaemia and diabetes mellitus.
  She was asymptomatic but was concerned that she
  might develop a stroke like her friend did.

3
CHD Risk Factors

• No past history of CHD/stroke/DM/IGT
• No family history of CHD/ Stroke
• Non-smoker
• No history of hypertension BP 120/80
• Not on any long-term medication
• Regular morning walk one hour/day
• Menopause age 55
• BMI 49 kg / (1.47 M)2 22.6

4
Screening Results

• TC 8.1 mmoles/L
• HDL 1.89 mmole/L
• TC/ HDL 4.3
• TG 1.5 mmoles/L
• LDL 5.53 mmoles/L (by calculation)
• FBS 4.4 mmoles/L

5
Management

• Dietary advice
• Continue regular exercise
• Repeat lipid profile in six months

6
Consultations 4 and 6 Days Later

• c/o dizziness, sweating, hunger and tremor during
  morning exercise, very worried about heart
  attack/ stroke
• Very compliant with diet, took half a piece of
  bread for breakfast, half a bowel of rice and 2
  oz of meat each meal

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Video
8
The Outcomes of Screening

• Four A E attendance
• Medical specialist referral
• Psychiatry referral
• Psychologist consultation
• Social worker service
• Dietician counselling
• Two hospital admissions

9
PYNEH Discharge Summaries

• Admitted to A E on 29-11-2001 for fearful
  feeling and whole body trembling, diagnosed as
  anxiety neurosis, referred to psychiatry and
  medical specialist OPD
• Admitted to Psychiatry 15-12-2001 to 11 -01-2002
  for anxiety disorder hyperlipidaemia ( TC 7.1
  TG 4.5 mmoles/L), discharged with gemfibrozil
  600mg bd and diazepam 2mg bd

10
Urgent Appointment on Feb 28, 02

• Acute Panic after conflicts with son
• Generalised muscle aches twitching
• Suicidal Impulses
• Insomnia, becoming dependent on diazepam
• Weight decreased from 49kg to 45kg

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Video
12

Age 75, Irresponsible, Extramarital affairs
Anxiety Neurosis treated by psychiatrist 82-83
lt-----
1982
44
38
42
Living in Australia
Broker,goes to Shunzhun often
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Management of the Patient

• Big dose of reassurance
• Low dose antidepressant to control panic attacks
  and insomnia
• Continue Gemfibrozil
• Regular follow up and blood tests
• Modification of eating habit

14
Video
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Outcomes of Treatment

• Weight 48.5Kg
• TC 5.7mmoles/L
• HDL 1.8 mmoles/L
• TC/HDL 3.2
• TG 1.4 mmoles/L
• LDL 3.3 mmoles/L (calcualated)

ALT increased from 33 U/L to 68 U/L (lt38)
16
If we have the chance to do it all again, should
we?
17
Wilsons Principles of Screening(Wilson
Jungner, Principles and Practice of Screening
for Diseases, WHO 1968)

• The problem is important
• Intervention can make a difference to the outcome

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Is hypercholesterolaemia important?

• Joint British Recommendations
• 10 year CHD risk gt30 should be treated now
• 10 year CHD risk lt15 needs no intervention
• The New NCEP Guideline III
• 10 year CHD risk gt20 should be treated
  aggressively
• 10 year CHD risk lt10, drug treatment may not be
  cost-effective

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Joint British Societies 10-year Coronary Risk
Predication Chart (British Cardiac Society et
al. BMJ 2000 320 705-708)
Women without Diabetes
Patients TC/HDL 4.3 risk ltlt 15
20
Framingham CHD Risk Scoring Table(www.nhlbi.nih.g
ov.guidelines/cholesterol/atp3xsum.pdf)

• Woman aged 70-74
• Age 14 points
• Non smoker 0 point
• Systolic BP 120-129 1 point
• HDL gt 60mg/dL -1 point (2)
• TC gt 280mg/dL 2 points
• Total 16 points (19)
• 10 year CHD risk of this patient 4 (8)

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Does primary preventive treatment make a
difference to the outcome?

• No effect of any treatment on all-cause mortality
  (www.clinicalevidence.org)
• Statins reduced CHD risk by 29 in women (LaRosa
  et al, JAMA 1999, 282 2340)
• Gemfibrozil reduced CHD risk by 34 in men, no
  data for women (Frick et al, NEJM 1987
  3171237-45)
• No evidence on effectiveness of diet

22
Possible Benefit for Patient

• Assuming a 30 RRR with treatment
• the reduction in 10 year CHD risk for this
  patient is from 4 to 2.8
• The NNT to prevent one CHD event in 10 years 83
  
• Cost/event 454, 425 - 1,281,478.5

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Balance the Benefit against the Harm

• Patient anxiety
• Quality of life
• Family conflicts
• Side effects of intervention, diet can be harmful
• Burden on health and social services

24
The Arrogance of Prevention (Sackett D.L., CMAJ
2002 167363-4)

• Aggressively assertive
• Target the asymptomatic
• Turn the well to the ill
• Presumptuous
• Intervention is beneficial
• Benefit is more than harm
• Overbearing
• Critical of those who dont conform

25
Consider the Whole Person

• The absolute risk of the problem for the
  individual
• The psychosocial context of the patient

26
Prepare for the Consequences of Positive Results

• The meaning to the patient
• The meaning to the family
• The necessary follow up management
• The implication on services

27
Conclusion

• In our attempt to prevent a possible harm, we
  must first do no harm.

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Further Reading

• Sackett, D.L. The arrogance of preventive
  medicine. CMAJ 2002 167363-4.
• Forde O.H. Is imposing risk awareness cultural
  imperialism? Social Sc Med 1998 47 1155-1159.
• British Cardiac Society et al. Joint British
  recommendation on prevention of CHD in clinical
  practice. BMJ 2000 321 705-708.
• Henley E et al. Treatment of hyperlipidemia. J
  Fam Pract 2002 51 370-376.