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Editorial A new therapy? C. Fernandez There is a progressively increasing contrast between the exaggerated speed of the current technological evolution – which leads us to believe in the existence of new, more or less radical solutions to everything, even to the “disease” problem -, and the apparently static proposal put forth by Wald and Law (1), based on the attempt to prevent both cardiovascular pathologies and contracted diseases by resorting – albeit in different manners – to the knowledge and skills we already possess and daily apply on thousands of patients. This article cannot and is not meant to discuss the details of the above mentioned proposal: we only emphasise that it suggests anticipating and stimulating elements which could – in the near future – bring about a revolution in our way of thinking and, consequently, of acting. It is now many years that the scientific progress in the medical field has been constrained into very rigid rational patterns, imposing the requirement to produce definite and continuous evidence concerning: 1) the diagnostic capabilities; 2) the validity of performable operations; and 3) the effectiveness of pharmacological treatments. It is likely that the limits which we are not able to surpass - such as those connected with the onset of the major diseases (i.e. cardiovascular and neoplastic diseases) especially in the Western countries where research is particularly advanced – are the very limits which seem insurmountable at the moment and have somehow clipped the wings of any theory parallel to science, forcing us to think only within the conventional tracks. In recent years, no new approaches have been suggested, but for the genetic assumptions, which aroused some concerns in the researches, especially linked to the fact that – initially at least – it would be very difficult to contrast the anomalies responsible for the onset of pathologies and, consequently, of diseases. However, at the time being, we tend to treat any pathological event by administering drugs and/or surgery, with or without the fitting of a prosthesis: to hypothesise a new, dominant factor unconnected with the traditional cause-effect model could cause the collapse of the very certainties to which we have always clung and on which we based all our scientific researches and/or “conquests” up to now. Also this framework contains new, “revolutionary,” generally unclear and destabilising elements. Actually, the adoption of such a certainty model in the past 50 years has driven away any “revolutionary” assumption, thus bringing serenity and a solid basis to the scientific world, with far-reaching repercussions even at the socio-economic and industrial level. The proposal of Wald and Law (1) - revolutionary in a certain way -, contains similar destabilising elements, both in the moral and in the economic context, and could push us to re-examine the cause-effect model, indirectly leading us to put up new forms of defence, thus completely changing the medical approach to alleged or contracted diseases. I do not think that we should presumptively reject this proposal, but rather, also due to its innovative features, that we should carefully analyse and examine it, hoping that it will prevent us from considering our patients as a homogeneous mass of individuals to be treated sic et simpliciter, and to always remember that the patient who turns to us, coming into our office for help to overcome “his/her” disease, is a special human being. REFERENCES 1. A strategy to reduce cardiovascular disease by more than 80%. N J Wald, M R Law. BMJ 2003;326,1419-24. 5
6 Forum virtuale su: Una nuova proposta strategica per ridurre la patologia cardiovascolare dell'80% Virtual forum: A strategy to reduce cardiovascular disease by more than 80% A. Lotto, C. Fernandez Nel Giugno di quest'anno sul British Medical Journal è stato pubblicato un articolo di N J Wald e MR Law dal titolo: "A strategy to reduce cardiovascular disease by more than 80%" (1). Le referenze dei due Autori sono indiscutibili e possono essere qui sintetizzate: entrambi lavorano presso il Department of Environmental and Preventive Medicine, Wolfson Institute of Preventive Medicine, Barts and the London, Queen Mary's School of Medicine and Dentistry, University of London, London EC1M 6BQ. Gli obiettivi, il disegno, l'outcome ed i risultati, nonché le conclusioni possiamo trasferirle direttamente dal testo originale: Objectives. To determine the combination of drugs and vitamins, and their doses, for use in a single daily pill to achieve a large effect in preventing cardiovascular disease with minimal adverse effects. The strategy was to simultaneously reduce four cardiovascular risk factors (low density lipoprotein cholesterol, blood pressure, serum homocysteine, and platelet function) regardless of pretreatment levels. Design. We quantified the efficacy and adverse effects of the proposed formulation from published meta-analyses of randomised trials and cohort studies and a metaanalysis of 15 trials of low dose (50-125 mg/day) aspirin. Outcome measures. Proportional reduction in ischaemic heart disease (IHD) events and strokes; life years gained; and prevalence of adverse effects. Results. The formulation which met our objectives was: a statin (for example, atorvastatin (daily dose 10 mg) or simvastatin (40 mg)); three blood pressure lowering drugs (for example, a thiazide, a ßblocker, and an angiotensin converting enzyme inhibitor), each at half standard dose; folic acid (0.8 mg); and aspirin (75 mg). We estimate that the combination (which we call the Polypill) reduces IHD events by 88% (95% confidence interval 84% to 91%) and stroke by 80% (71% to 87%). One third of people taking this pill from age 55 would benefit, gaining on average about 11 years of life free from an IHD event or stroke. Summing the adverse effects of the components observed in randomised trials shows that the Polypill would cause symptoms in 8-15% of people (depending on the precise formulation). Conclusion. The Polypill strategy could largely prevent heart attacks and stroke if taken by everyone aged 55 and older and everyone with existing cardiovascular disease. It would be acceptably safe and with widespread use would have a greater impact on the prevention of disease in the Western world than any other single intervention.
Page 1 and 2: Organo Ufficiale dell’Associazion
Page 3 and 4: Giornale Italiano di Cardiologia Pr
Page 5: 4 Editoriale Una nuova terapia? C.
Page 9 and 10: 8 We calculated the combined effect
Page 11 and 12: 10 IL COMMENTO DEL CO-DIRECTOR Il c
Page 13 and 14: 12 Nel Settembre di quest'anno dopo
Page 15 and 16: 14 durre ben accertati fattori di r
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Page 19 and 20: 18 pio tiazide, betabloccante e ACE
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Page 25 and 26: 24 tina (atorvastatina o simvastati
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Page 29 and 30: 28 Indipendentemente dalla sua vali
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56 Giornale Italiano di Cardiologia
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58 Giornale Italiano di Cardiologia
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60 esame emocromocitometrico: emato
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62 Discorso sul metodo: il medico p
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64 È opportuno riaffermare con chi
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66 Bibliografia Ragionata Annoted B
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68 Confronto fra Angioplastica Prim
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72 21/23 Gennaio - Monte-Carlo IFEC
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Edizioni Sicex s.r.l.
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