2003 Study Found (some) "classical risk factors" for CVD Weren't Risk Factors After All

Surely, maybe because the patients were already on the proper drugs.(Yet another shameless rip-off from a Kendirck book, but with better citations.)

Revised: 05-21-2023 [minor edits]

This article is inspired by and shameless borrows from Kendrick’s The Great Cholesterol Con (2008, his first book, I believe), chapter 7. Kendrick found a study “uninentionally hilarious” and lampoons its illogical conclusions.

This particular book isn’t well footnoted, but I was able to locate the study, or more precisely, its abstract. It’s worth mentioning that I’ve verified some of his claims, and they are supported by his erratic citations. I think, but can’t be sure of course, that in this case Kendrick has only used the abstract of a paper, not the detailed study. But that of itself doesn’t diminish his credibility in the least. I don’t have access to the actual studies, including at my local university. So the abstract is all I’ve got…

In any case, the parts to dissect are short enough to cut and paste in their entirety.

Here’s the URL for the abstract: [Bolding mine; well some of it — parts are in the original.]

https://pubmed.ncbi.nlm.nih.gov/14555885/

Abstract

Background: Both EUROASPIRE studies revealed the suboptimal management of coronary patients regarding lifestyle changes and prophylactic use of cardiovascular drugs. We report here on the mortality follow-up of the EUROASPIRE I cohort over a median period of 4.4 years.

Design and methods: The EUROASPIRE I cohort consisted of a consecutive sample of patients aged < or =70 years from nine European countries, hospitalized because of coronary artery bypass graft, percutaneous transluminal coronary angioplasty, acute myocardial infarction or myocardial ischaemia. Baseline data, gathered in 1995-96 through standardized methods, were linked to cause-specific mortality as registered up to 1 April 2000 in 3343 patients.

Results: After adjustment for age, gender and diagnostic category according to Cox modelling, smoking, previous coronary heart disease and diabetes proved significant predictors of total, cardiovascular (CVD) and coronary heart disease (CHD) mortality. Obesity, low education, raised blood pressure, elevated total cholesterol and low HDL cholesterol, however, were not significantly associated with higher mortality rates. In multivariate analysis, smoking and diabetes emerged as the strongest predictors of CVD [risk ratios (RR) 2.2 and 2.5 respectively] and CHD mortality (RR 2.4 and 2.4 respectively).

Conclusions: The results of the mortality follow-up of the EUROASPIRE I patients underline the importance of smoking and diabetes in the secondary prevention of CHD. Failure to find statistically significant associations between other classical risk factors, such as blood pressure and plasma lipid levels, and mortality may be related to the extensive use of antihypertensive and lipid-lowering drugs in this cohort.

Now, the correlations the study found are reasonable enough. Smoking and diabetes are rough on the circulatory system’s health. Prior CVD/CHD is sort of a “duh!” yet admissible predictor of future risk, too. With the exception of earlier heart disease, the Puritan in me feels obligated to point out that the other two risk factors are mostly self-inflicted. Certainly so in the case of smoking (“You weren’t born with a cigarette in your mouth” as some wise ass once observed) and very likely in the case of diabetes usually due to poor diet.

Aside: although he doesn’t mention it in this book (perhaps because it was still several years in the future) Kendrick posits in Doctoring Data, that obesity alone poses little risk to health. More to the point, that slightly overweight or obese actually have a lower mortality rate than normal weight. Highest mortality was at the underweight and “Obese II” end of the range. At least at the low end, this is not unlike what he reports for “cholesterol” levels — the higher death rates usually are at the low end. The conclusion is good news, I suppose, if one is a fat, uneducated slob. I mean no offense and likely none is taken, as such cretins are unlikely to number among my readers.

Anyway, back to the current study. Let’s parse those anomalies, shall we? For now we’ll confine ourselves to blood pressure and “cholesterol” (actually, lipids). Here are two of the cornerstone tenets of cardiology, claimed causations of CVD/CHD, and they found no significant association with higher mortality? For shame!

Their conclusion seems to wish hopefully (“may be”) the surprise results might be laid to the cohort being extensively medicated to treat those conditions. That claim sounds reasonable on the surface. After all, we know, at least we’re told, that the cohort is a rather sick group, people who’ve had CVD/CHD. But its that claim supported by evidence? If patients were already being successfully treated for blood pressure and high lipids, can those still validly be labeled risk factors? And finally, if they are still risk factors, does that mean the drugs to treat those conditions aren’t of much avail? (I’m an insolent little bastard, aren’t I?)

To my skeptical ear, all this sounds like a “cope,” an attempt to explain away an unfavorable finding.

Let Kendrick speak a bit more. It’ll save me the effort of finding something original to contribute.

Here’s his rebuttal to the claim that the cohort was medicated:

Perhaps they should have read the conclusion of a sister EUROASPIRE paper

https://pubmed.ncbi.nlm.nih.gov/11259143/

on the management of said risk factors:

This European survey of coronary patients shows a high prevalence of unhealthy lifestyles, modifiable risk factors and inadequate use of drug therapies to achieve blood pressure and lipid goals [my emphasis].

The actual figures were that 58 per cent had total cholesterol concentrations over 5.5 mmol/l [~= 215 in US units*] and more than 50 per cent had blood pressure above 150/90. In short, there was not ‘extensive use of antihypertensive and lipid-lowering drugs in this cohort’. Or if there was, they weren’t doing much to lower blood pressure or cholesterol levels. Another instant ad-hoc hypothesis bites the dust.

What EUROASPIRE actually proved, rather nicely, is that smoking, already having heart disease and having diabetes are true risk factors for heart disease. Whereas a high cholesterol level, and a high blood pressure, are not. Did the authors of this study consider this possibility? They did not. In this area, the ability of researchers to ignore the results of their own research is quite mind-bending.

As a quick aside, discovering that ‘already having heart disease’ is a risk factor for dying of heart disease hardly ranks alongside the discovery of penicillin.

[end of Kendrick quote]

In any event, my curiosity is piqued. I look forward to seeing the study itself to see if I can suss out any detail.

Addendum: Liberal buddy looks at the claim, predictably cites irrelevancies, yet may have found a flaw in my argument.

I shared the two studies (not this article) with a friend who is well-educated (MA degree), highly intelligent and nonetheless a liberal Democrat. She replied:

I don't have the same "read" as you at all.  Firstly, the aim of the study was not to determine whether diet-lypid hypothesis is valid.  That was already a given.  The purpose was to determine "in patients with established coronary heart disease whether the Joint European Societies' recommendations on coronary prevention are being followed in clinical practice."  Secondly, the conclusion of the study was  "There is considerable potential throughout Europe to raise the standard of preventive cardiology through more effective lifestyle intervention, control of other risk factors and optimal use of prophylactic drug therapies in order to reduce coronary morbidity and mortality." So it showed the patients were not following the prescribed dietary recommendations. And that lipid-diet control (lifestyle intervention) and use of drug therapy has significant potential to reduce cardiac problems.   Nowhere does it say saturated fats,etc do not cause cardiac issues.   I do not see the two studies as being contradictory in any way.

At first I thought to myself with glee: Aha! Typical progressive behavior: fail to address the topic and shift focus elsewhere. To which I responded:

Thank you for reading [the two study abstracts]. Strictly speaking you are correct; the studies did not directly look at diet or saturated fats. This was, however the topic of the section of a book and I will copy the short section below to make it clearer. You are right that the studies don't claim that lipids cause cardiac issues, but it DOES say they failed "...to find statistically significant associations between other classical risk factors, such as blood pressure and plasma lipid level...."and then they conjecture that may be due to "... extensive use of antihypertensive and lipid-lowering drugs in this cohort"

Yet the second study specifically found in the same cohort "...a high prevalence of unhealthy lifestyles, modifiable risk factors and inadequate use of drug therapies to achieve blood pressure and lipid goals"

So yes, there is a contradiction: the first claims "extensive use" of therapeutic drugs, and the second found "inadequate use" of same.

She replied:

They were two different cultural groups being studied.  You cannot compare one to the other.  That's "apples to oranges."  Conclusions from one study have no relevance to the conclusions from the other. 

Credit where due: She may be right. (I hate it when a Progressive is right!) The first study cites EUROASPIRE I. The second, EUROASPIRE II. I will have to look at the individual studies. It’s quite possible that similar data were collected from both cohorts. I would be greatly surprised if the two cohorts were highly different, but until I look at each study, that, I confess, is an ad-hoc hypothesis too! But for the time being, my critic’s objection stands.

*Measuring lipids is the only case of measurement I know of where Europe uses one metric standard and the US uses a different metric standard. Who knew there were two different metric systems?