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NICE, hypertension & the cricket world cup

Rob Walker - 4 Jul, 2019

Like many I have been glued to the Men's cricket World Cup this summer, which has brought back memories of my introduction to the game around the time of the World Cup in 1983. As with many young pretenders who started off on some form of street/garden cricket, we had a ‘six and you’re out’ rule. Whether this be tonking the ball into the pond, the dustbins or through the next door neighbour's window, you have the initial excitement of scoring a maximum 6 runs, which quickly turns to disappointment as you lose your wicket and have to hand over the bat. This is an important lesson for fledgling cricketers - weighing up the balance of being positive and scoring runs, without over-stretching yourself and getting out.

I’m in the middle of reviewing the draft NICE hypertension guideline in readiness for our Autumn courses and couldn’t help but feel there were a few lessons and analogies to be drawn from cricket for medical guidelines (non-cricketers bear with me!). It is obviously a draft and can still be altered before the final publication, but if it remains in its current form it is going to be controversial. The most controversial recommendation is to lower the 10 year CVD risk threshold for starting drugs in those with stage 1 hypertension (140/90) from 20% to 10%, and as Brodersen and colleagues argued in an excellent BMJ editorial recently (BMJ 2019;365:l1657), this change ‘has implications beyond changes to disease definitions, including risks to our wellbeing and shifts in our conceptualisation of health and disease’. The lessons you learn from street/garden cricket, by weighing up the benefits/risks of a big shot, translate into proper cricket when a six becomes an option - sometimes it’s the right option to go for the big shot (short boundary, following wind), but sometimes not. Likewise, significant guideline changes (going for the big shot) may be justified if the conditions are right (i.e. conclusive evidence), yet the evidence for this change is weak; NICE admit that ‘the area of most uncertainty was in treating stage 1 hypertension, particularly for people with a lower cardiovascular risk’.

So, have NICE assessed the risks of this significant shift? They ‘were mindful of the additional population that would be affected by lowering the threshold’, yet the decision to lower the threshold seems to have been made predominantly on a cost-effectiveness analysis on potential public health gains, without any mention of the known harms of labelling people with hypertension as discussed in the BMJ editorial above, including absenteeism from work, lower self-rated health and psychological harm. 

Yet the biggest risk in my view is this - loss of confidence in the guideline itself. We are painfully aware of the harm that has been caused by the ‘statin wars’ - the loss of confidence in the evidence and recommendations with both clinicians and the public has helped no one, especially our patients. My worry is that we could face a similar scenario with this guideline and the ‘hypertension wars’ is a real risk. Like a good game of cricket, medical guidelines need opposing parties to play ‘hard, but fair’ - we need to have critical but fair discourse on a given subject, yet we still need to respect the opposition and their views. If confidence and respect breaks down, we lose that ‘hard but fair’ discourse and we end up with entrenched views and people believing their own rhetoric too much - this was apparent with ‘sandpapergate’ and the Australian men's cricket team last year, as it has been in the ‘statin wars’ in our medical world. In cricket the ultimate arbiter is the umpire, and like the patient in front of us we need to remember that they are the ones who need to make the final decisions, irrespective of what our views may be. 

Cricket as a game has had to adapt based on public opinion - the longer formats are being replaced by the shorter formats we see in the World Cup, yet current medical guidelines have little input from the wider public and the BMJ editorial rightly argues that outcomes need to be more meaningful to patients and the public and that ‘diagnostic thresholds and the boundaries of disease should be defined not by disease specialists but by financially independent, people centred panels that are led by primary care’. Only time will tell if the hypertension guideline is published in its current format, or if alterations are made, but my worry is that the current iteration has not weighed up the wider risks adequately, particularly around clinician and public confidence, and that we may see the ball sailing through the next door neighbour's window for a ‘six and out’ and ultimately a disappointing end.

NICE, dense amnesia and the man who forgot he’d made love with his wife

Simon Curtis - 11 Jul, 2019

‘Yesterday my wife and I made love and I can’t remember anything about it’ is one of the more unusual openings to a consultation I’ve had. This case was over 20 years ago, I was a newly qualified GP, but I’ve never forgotten it. Using my recently acquired consulting skills I naturally followed with an open question: ‘so, do tell me more about it’. My frustrated and now irritated patient then pointed out to me that that was the whole point, he couldn’t remember. But his wife could, and she proved to be a good witness.

Having woken feeling fine, which he could remember, he then had 4 or 5 hours during which he could remember nothing and during which the said love making, and several other quotidian activities, had occurred. During this period once he was reminded by his wife what had recently happened he became increasingly anxious and agitated as he realised he could not remember it or indeed retain any new information leading to him to repetitively question his poor wife. After 6 hours or so everything came back to normal and he could retain new information, but those hours remained lost in his recall.

Exploring his ideas, concerns and expectations further (remember, I was newly qualified…) he and his wife were worried that he may have had an orgasmic stroke as apparently the said act was, according to his wife, ‘quite vigorous’ (‘and I can’t remember!’ moaned my patient). This then struck me as plausible that he may have had a vascular event, and he had a couple of risk factors, so I referred him urgently. He was scanned, no cause was found and he was discharged as my first case of ‘transient global amnesia’. I have seen a good few cases since, but once seen (or experienced!) TGA is rarely forgotten.

Like a lot of sudden new neurological symptoms TGA or dense amnesia creates a conundrum for us. We don’t want to over refer and yet, increasingly so in a time of defensive medicine, we don’t want to miss anything. So should we refer acutely or should we reassure?

To help answer this, and many other questions for other new neurological symptoms (from patients with blackouts to anosmia to vertigo etc), NICE have recently published a fascinating new guideline advising about Suspected neurological conditions, recognition and referral 2019 NG127. Rather confusingly, they call TGA ‘dense amnesia’ but they reassure us that it is benign and that referral is NOT necessary if it is a single episode that lasts less than 8 hours, there is complete recovery and there are no features suggestive of an epileptic seizure. If it happens recurrently, it could be transient epileptic amnesia and then does need referral. NICE are to be congratulated on producing such a useful guideline for primary care, but it is long (74 pages!) and complex. We shall be covering it for you, with illustrative cases and keep it simple summaries, on our upcoming Autumn courses.

So, what causes TGA or dense amnesia? That we don’t know, but we can reassure our patients that it is benign and the risk of recurrence is low. It can be triggered by precipitating events including sex, swimming in cold water or acute stress. I can imagine my patient would say he’d be happy to avoid two of those…