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A five-point plan to reduce heart attack deaths in Australia

Out of the 10,021 Australian who died of a heart attack in 2010, 5,305 were experiencing their second such event. Systematic national reforms are needed to reduce the alarming number of people having a…

Heart disease is a lifelong problem that needs to be managed properly. Peter Hartl

Out of the 10,021 Australian who died of a heart attack in 2010, 5,305 were experiencing their second such event. Systematic national reforms are needed to reduce the alarming number of people having a second heart attack and ensure the health-care system isn’t failing those who survive the first time.

As well as lives lost, deaths from heart attacks result in enormous costs – over $8.4 billion annually. And this figure doesn’t account for the time lost at work, or financial, emotional and other family costs.

A failing system

Most repeat heart attacks are preventable but after having their first heart attack many people slip back into old habits. They stop taking medication, don’t participate in cardiac rehabilitation programs and don’t make or maintain simple lifestyle changes such as stopping smoking, being physically active and following a healthy diet.

Indeed, many people seem to think a heart attack is a one-off - once it happens, it’s past - but heart disease is a lifelong problem that needs to be managed properly. And there’s no quick fix. There’s also a misconception that a stent or bypass is as good as a cure, but that’s simply not the case.

Unfortunately, our health-care system is not geared towards the complexity of managing heart disease. Cardiac rehabilitation programs are short, lasting only a few weeks, and are used by less than a third of heart attack survivors.

The risk of dying from a heart attack increases the second time around – 20.7% for women and 13.7% for men. Given that one in four people who have a heart attack go on to have a second one, it’s critical to put an appropriate treatment program into place.

A five-point plan

Reforming how we care for heart attack survivors should be a national priority. Such reform, along with increasing the utilisation of existing schemes, is achievable through the following five-point plan detailed in today’s edition of the Medical Journal of Australia .

  1. Develop and implement a national approach to secondary heart attack prevention that provides a clear and personalised path for all patients including ongoing support for lowering risk and long-term follow up.

  2. Bridge the gap between hospital and primary care by implementing a case management approach that’s recognised by Medicare. This should provide patients with ongoing support and guidance.

  3. Increase awareness and utilisation of existing services by creating a web-based national inventory of prevention services, and potentially a public media campaign. Many health providers and patients are unaware of all relevant services, and the inventory could include a range of programs and schemes including cardiac rehabilitation, Heart Foundation programs, Medicare-rebatable schemes (such as access to allied health and psychology services via chronic disease management plans and home medicines reviews), among others such as Quitline and Aboriginal and Torres Strait Islander services.

  4. Develop a system for monitoring and maintaining performance with measures to facilitate clinical practice improvement. These measures should assess service delivery features (access and timeliness, for instance) as well as end health outcomes including hospital re-admissions and coronary heart disease deaths.

  5. Implement a National taskforce and a communication strategy involving state and federal government, private health funders, Medicare locals, consumers and health professionals. Such a cohesive and multidisciplinary group is essential to raise the profile of the problem and provide leadership.

Narrowing the evidence-practice gap in secondary prevention for heart disease is will save lives and money. Raising it as a national priority, increasing utilisation of existing schemes and developing similar strategies to those effectively implemented for management of other chronic diseases in Australia offer excellent prospects for progress.

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45 Comments sorted by

  1. Tim Kottek

    logged in via Facebook

    Thanks, I find it useful to be reminded of the facts, heart disease is chronic. I wonder how much of the "relapse" behaviour is due to deeper causes that won't be addressed by communications campaigns or challenges to primary care? Perhaps in the lucky country some people prefer not to live and take a way out that is available - tobacco, alcohol, etc. Root cause perhaps unknown

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  2. rory robertson
    rory robertson is a Friend of The Conversation.

    former fattie

    Heart attacks not driven by smoking typically are driven by decades worth of poor diet. As you rightly note, Julie, simple lifestyle changes like stopping smoking, being physically active and following a healthy diet can make a huge difference.

    But what is "a healthy diet"? This is a matter of great controversy and debate. On one increasingly accepted view, poor modern diets generally reflect incompetent US nutrition advice in the 1970s that quickly spread the unhealthy but now-standard low-fat…

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    1. Sue Ieraci

      Public hospital clinician

      In reply to rory robertson

      "On one increasingly accepted view, poor modern diets generally reflect incompetent US nutrition advice in the 1970s that quickly spread the unhealthy but now-standard low-fat, hi-carb, hi-sugar diet across the world."

      Over-consumption of sugar has nothing to do with nutrition advice from within the profession - which has always advocated balance. It is a lazy response to the marketing of sweet drinks and other sugar-added foods by the food and beverage industry.

      Simplistic solutions generally…

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    2. John Doyle
      John Doyle is a Friend of The Conversation.

      architect

      In reply to Sue Ieraci

      Here we go again, Nutritionists defending the indefensible! On their watch CVD, Metabolic Syndrome, Diabetes and Obesity have all becoming an epidemic and it's all due to Bad Science. Bad science which said to reduce saturated fats and increase use of industrial processed polyunsaturated oils to reduce heart attacks. Well it's wrong to say this when we have eaten such fats [and fruit oils like olive oli] for thousands of years with no such bad outcomes. Because fat carries flavour reducing fat in…

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    3. Sue Ieraci

      Public hospital clinician

      In reply to John Doyle

      Actually, John Doyle, architect, mortality rates from cardiac disease are falling - see ABS figures at http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/3303.0Media%20Release12010?opendocument&tabname=Summary&prodno=3303.0&issue=2010&num=&view=

      "The proportion of deaths from heart disease has decreased over the past decade, accounting for 15% of all deaths in 2010, compared with 20% in 2001, according to figures released today by the Australian Bureau of Statistics (ABS). "

      This may well be due to a significant reduction in smoking rates. According to the Cancer Council, 72% of Australian men smoked in 1945, while only just over 16% smoked in 2010.

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    4. rory robertson
      rory robertson is a Friend of The Conversation.

      former fattie

      In reply to Sue Ieraci

      Great, here to correct me again is Sue: she who is oh so wise in the ways of science, yet an apologist for the status quo on nutrition advice (and of negligent published papers with false conclusions).

      Look around, Sue. The world is getting fatter, more diabetic and heart disease remains a big problem, as Julie highlighted above, despite the gradual extinction of smoking in Australia.

      Sorry to break it to you, Sue, but there's a teensy bit of evidence that modern diets are unhealthy; indeed…

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    5. John Doyle
      John Doyle is a Friend of The Conversation.

      architect

      In reply to Sue Ieraci

      So what, Sue?
      It's certainly not due to any nutritional advice from your profession.
      Far more likely the medical profession is finding better ways to save people.

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    6. John Doyle
      John Doyle is a Friend of The Conversation.

      architect

      In reply to rory robertson

      See, Rory
      You are part of the cohort who can see through the crappy advice dispensed by nutritionists and lazy journalists to the by now in-your-face epidemic of bad health.
      We are better off being non specialists because we will not get paid to dispense faulty advice by vested interests, which is such a big taint on that industry.
      A lot of food fads are founded by religious cults who have no interest in science, just influence. Ellen White has been exposed as a fraud, yet she founded an ongoing "church" still peddling the same bad advice today.

      We have results!!!

      They have theories - and which don't work. as Sue says "What would I know?"
      Well as long as you tout low fat diets you are on the losing side, Sue.
      Low fat diets [and sodas] gave rise to the sugar epidemic, etc. etc.

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    7. rory robertson
      rory robertson is a Friend of The Conversation.

      former fattie

      In reply to Sue Ieraci

      Thanks, Sue. I see you resisted the urge to correct me, recognising that I had made a series of strong points via Gary Taubes's profoundly important history of nutrition science, "Good Calories, Bad Calories".

      Yes, Sue, it appears that US and global "heart healthy" nutrition advice took an incompetent "wrong turn" in the low-fat, high-carb, pro-sugar direction in the 1970s. Australia's nutrition profession jumped on that global bandwagon, apparently to the detriment of everyday Australians…

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    8. John Doyle
      John Doyle is a Friend of The Conversation.

      architect

      In reply to rory robertson

      They'll hope we'll just go away, Rory
      Or like with me they will pick on a single word and write about that
      so completely missing the main argument.

      And by the way, I still say fructose is a poison.
      It's not a scheduled poison like arsenic etc, but considering the damage it does to our bodies it does qualify as a poison.

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    9. Sue Ieraci

      Public hospital clinician

      In reply to John Doyle

      "Well as long as you tout low fat diets you are on the losing side, Sue." John Doyle - I am not a nutritionist and I don't tout any "diet" except for balance and moderation.

      Balance in nutrition and energy intake: not absolutism. Doesn't sell books, though, and not populist enough, I guess.

      But why listen to people who are brainwashed by the study of how the human body works and by review of the research, when it's so much nicer to believe the simplistic messages?

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    10. Sue Ieraci

      Public hospital clinician

      In reply to rory robertson

      Getting longer again, Mr Robertson.

      Somewhere in there, you said "Yet the nutrition profession's highest-profile advice over the past 30 years has been to go "Low fat". How? By replacing particularly evil animal and other fats with carbohydrates, including refined sugar (itself 100% carbohydrate)."

      Please show me evidence that the nutrition profession advised that excess fat should be replaced by refined sugar?

      Why are people trying to blame health care workers for their poor choices?

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    11. Sue Ieraci

      Public hospital clinician

      In reply to John Doyle

      "And by the way, I still say fructose is a poison."

      Say what you like, John Doyle - you're still wrong.

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    12. rory robertson
      rory robertson is a Friend of The Conversation.

      former fattie

      In reply to Sue Ieraci

      Sue, I'd be surprised if any careful, objective reader is able to miss the obvious and deliberate substitution of carbs including sugar for fat documented in the direct quotes I provided above. (Readers, correct me if I am wrong.)

      Also, Sue, I note that you went completely limp on your mistaken suggestion that Gary Taubes is unreliable. That was sensible. I say again, let's hear from influential nutritionists still parroting the discredited low-fat mantra; let's hear what they have to say regarding…

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    13. Sue Ieraci

      Public hospital clinician

      In reply to rory robertson

      Chris Wood seems to understand the point that you don't understand, Mr Robertson - "in unnaturally large quantities."

      I challenge you to find any nutritionist or health care worker who ever advised anyone to consume sugar "in unnaturally large quantities". It may be that you used to do so yourself, but you can hardly blame the entire health care professions for that.

      Many things are harmful "in unnaturally large quantities" - whether it be fibre, or Vitamin D, or potassium, or salt. And yet, in appropriate amounts and in balance, all these things are essential.

      However many more paragraphs you want to add about fructose, your favourite authors, Sydney University or the nutrition profession, the facts remain. It's all about moderation and balance.

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    14. Tom Hennessy

      Retired

      In reply to Sue Ieraci

      Br Med J. 1915 June 19; 1(2842): 1069.
      Since anascara is almost universal after a certain age , one might wonder WHERE someone would even FIND a heart failure patient who ISN'T anascaric and therefore eligible for venesection to lower blood volume / hypervolemia / anascara which , as evidenced , leads to zero deaths versus over fifty percent who remained hypervolemic.

      Copyright notice
      BLOODLETTING IN PNEUMONIA
      John Haddon
      BLOODLETTING IN PNEUMONIA.
      Sir, Dr. Balms's communication in…

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    15. Tom Hennessy

      Retired

      In reply to Tom Hennessy

      "Pulse of very high tension, who was kept for a year by one
      venesection"

      Which makes sense . because , hemoglobin increases blood pressure.

      "Hemoglobin Level Is Positively Associated With Blood Pressure in a Large Cohort of Healthy Individuals "
      "Hemoglobin level is positively associated with both systolic and diastolic blood pressures in healthy individuals."

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    16. Tom Hennessy

      Retired

      In reply to Tom Hennessy

      The theory being , since higher hemoglobin increases the 'thickness' of the blood / blood viscosity, it also raises blood pressure.

      "The viscosity of a fluid is related to the ease with which its
      molecules flow past one another. Measurement of viscosity could also be thought of as measuring how thick a fluid is. As viscosity
      increases, fluids flow less easily. (Think of the ketchup commercial on television where the watery ketchup pours quickly while you wait in anticipation for the other…

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    17. rory robertson
      rory robertson is a Friend of The Conversation.

      former fattie

      In reply to Sue Ieraci

      Sorry, Sue, unlike your examples of Vitamin D, potassium and salt, refined sugar delivers absolutely nothing "essential" to the human body. As a "Public hospital clinician", you should not pretend otherwise. Moreover, refined sugar clearly IS being consumed in unnaturally large quantities, assisting millions - even billions - globally to become fat and diabetic (see chart at http://www.australianparadox.com/part-2 ).

      Again, Sue, this unhealthy process in Australia is being helped along by…

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    18. Sue Ieraci

      Public hospital clinician

      In reply to rory robertson

      "Dr Sue Ieraci, by contrast, has been prepared to confirm only that Rory Robertson has no idea about anything that matters."

      On the contrary, Mr Robertson. I've only read your views about sugar and the University of Sydney (many times over). I have no idea what your ideas are on anything else "that matters".

      I will politely decline your invitation to join your crusade. You might consider teaming up with Mr Hennessy - he seems to have an interest in health matters, and the required tenacity.

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    19. rory robertson
      rory robertson is a Friend of The Conversation.

      former fattie

      In reply to Sue Ieraci

      Very good Sue. That was quite clever. Touche.

      I'm sorry that you couldn't be any help on the issue of scientific integrity at your alma mater, the University of Sydney. Of course, you are conflicted on that matter, so it always was a long shot.

      Nice move hooking me up with Mr Hennessy. I hope you won't mind me linking you and David Driscoll, as soulmates in your common determination to overlook deliberate misinformation and integrity issues at the highest levels of science at the University…

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  3. Jan Golembiewski

    Researcher in Environmental Determinants of Mental Health at University of Sydney

    Should there be a 6th point?
    The same data source quoted by Julie Redfern shows that just over 50% of the deaths from coronary heart disease occur in a repeat event, but just over 200% of the costs associated with coronary heart disease occur are associated with the first event.

    The five-point plan is a second line of defence. It’s a great start at tackling half the deaths from heart disease, but tackling the issue earlier, before the first event can also prevent deaths from second events. Not…

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  5. John Kerr

    IT Education

    How refreshing it is to see an articles that doesn't mention the intensive use of pharmaceuticals to solve our problems. Good diet, exercise and education, follow-up - this all makes such good sense. Now, get the message through to doctors. I have not had a heart attack but found I was being prescribed medication that the most eminent research had shown to have NO benefit at all to people such as myself. Let's keep the good bits in and the doubtful pharmaceuticals out. Let's let doctors know that a five minute check up on medications is not the way to change people's life styles.

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  6. Sue Ieraci

    Public hospital clinician

    Thanks for the article, Julie. What appears to be missing from the plan are the specifics of what is to be achieved in each step. What are the actual interventions that are evidence-based?

    For example, for Step 1, what are evidence-based steps that are shown to be effective in secondary prevention?

    For cardiac rehab, what is known to be effective in secondary prevention and how long should it last?

    What is the evidence for the various medications? Aspirin? Other platelet inhibitors? How important is blood pressure control? How important are lipids?

    Is there somewhere where all this evidence is summarised?

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  7. George Crisp

    Medical Practitioner

    Another aspect that should be addressed is the role of air pollution, both acutely and with chronic exposure. According to Tim Nawrot's meta-analysis in the Lancet Mar 2011:

    "In view of both the magnitude of the risk and the prevalence in the population, air pollution is an important trigger of myocardial infarction, it is of similar magnitude (PAF 5–7%) as other well accepted triggers such as physical exertion, alcohol, and coffee"

    A multitude of studies have reconfirmed the findings of the Harvard Six Cities and American Cancer Study of the 1990's which showed the correlation of air pollution, especially particulate matter, with cardiac mortality and morbidity at levels well below air quality standards.

    Improving air quality has been shown in both US and Europe to have significant beneficial economic effects through improved productivity and reduced health costs.

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  8. Ron Gawi

    General Manager at Highlands Pacific

    Cruising along midlife accompanied by a comfortable life myself, this article reminds me of the scores of friends, acquaintences and public figures in the same category who have succumbed to this killer and more importantly off course, helping myself/ ourselves to recognize and remove any lifestyle risks that contribute to heart attacks. I appreciate the article however, I couldn't avoid commenting on the misconstrued first impression I had, and english being my 4th language, upon reading of the first sentence of the article which implies that half of the 10,000 or so deaths from heart attacks are having their second "deaths" .

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    1. Julie Redfern

      Senior Research Fellow, Cardiovascular Division at George Institute for Global Health

      In reply to Ron Gawi

      Thanks for your replies everyone. It is great to hear people discussing and talking about the issues. The MJA report and piece written here are clearly brief and overarching. It is complex and challenging but one thing is clear - we can do better. All forms of prevention are important and every person is different. Our goal is to maximise engagement with secondary prevention on all levels. The problem is definitely international. As our population ages and medicine advances we have more and more people surving initial events and hence more and more people are in need of secondary prevention. Keep up the great work everyone!

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  9. Julie Redfern

    Senior Research Fellow, Cardiovascular Division at George Institute for Global Health

    Thanks for your replies everyone. It is great to hear people discussing and talking about the issues. The MJA report and piece written here are clearly brief and overarching. It is complex and challenging but one thing is clear - we can do better. All forms of prevention are important and every person is different. Our goal is to maximise engagement with secondary prevention on all levels. The problem is definitely international. As our population ages and medicine advances we have more and more people surving initial events and hence more and more people are in need of secondary prevention. Keep up the great work everyone!

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    1. John Doyle
      John Doyle is a Friend of The Conversation.

      architect

      In reply to Julie Redfern

      Yes, Julie
      Good stuff, but we amateurs would like to see better prevention.
      Is it true 1 in 27 died from heart attacks in 1900, but 1 in 2 are affected now?
      I can't recall where I saw that. Sound s a bit extreme.
      Whatever even if it was anything like that then the problem is immense now.
      It doesn't look like the food industry will change it's tune. In fact the food industry is funding or helping to fund the various Heart Associations in western countries. This means they have influence and they…

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    2. Sue Ieraci

      Public hospital clinician

      In reply to John Doyle

      John Doyle - I quoted the 2010 ABS figures above - "The proportion of deaths from heart disease has decreased over the past decade, accounting for 15% of all deaths in 2010, compared with 20% in 2001, according to figures released today by the Australian Bureau of Statistics (ABS). "

      That's FIFTEEN - not fifty.

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  10. Tom Hennessy

    Retired

    Too much blood has been shown to be bad for the heart , 55% death versus 0% death.

    "This is the largest published study measuring blood volume and patient
    outcomes. Congestive heart failure is the number one cause for admission to
    hospitals for patients over 65 years of age and results in annual healthcare
    costs exceeding $38 billion.
    The study followed severely ill congestive heart failure patients for a median
    follow up of 719 days. During the first year, the major finding was a 39% death rate in patients that were hypervolemic (excess blood volume) vs. 0%
    death rate for those who were normovolemic/hypovolemic (normal blood volume/mildly reduced blood volume). For those hypervolemic patients that were followed for a median duration of 719 days, the death rate was almost 55% vs. 0% for those patients who were normovolemic to slightly hypovolemic."
    http://docnews.diabetesjournals.org/cgi/content/full/1/2/22

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    1. Sue Ieraci

      Public hospital clinician

      In reply to Tom Hennessy

      Mr Hennessy - if you look up the pathophysiology of heart failure, you will see that it's not so much about "too much blood" as too much fluid (not cells).

      Cardiac failure involves imbalance in the renal/hormonal system that controls fluid excretion, resulting in excess fluid retention, that then pools in the lungs (left heart failure) or ankles (right-sided heart failure). Congestive cardiac failure certainly does have a high mortality rate - especially untreated.

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    2. Tom Hennessy

      Retired

      In reply to Sue Ieraci

      CHF is accompanied by increased red blood cells / erythrocytosis / polycythemia which causes hypervolemia , too much blood.

      "Plasma erythropoietin levels are elevated in a large cohort of patients with CHF"
      "Augmented packed red blood cell volume in patients with severe CHF"

      Hypervolemia is treated with phlebotomy which lowers the volume of blood and polycythemia is also treated with phlebotomy to lower red blood cells which also contribute to elevated fluid level.
      One can say the cause is volume of fluid , BUT , the treatment remains the same , phlebotomy.
      One might wonder whether you too are fond of pedantic arguing.

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    3. Sue Ieraci

      Public hospital clinician

      In reply to Tom Hennessy

      "One might wonder whether you too are fond of pedantic arguing."

      Very amusing, Mr Hennessy - a bit of pot calling kettle black.

      Heart failure happens to be one of the conditions seen daily in my specialty. I am old enough to remember when venesection was used to treat cases that didn't respond to the (then) treatments of morphine and diuretics.

      That has all now been replaced by much more effective - and safer - treatments like nitrates and non-invasive ventilation (CPAP and BiPAP). I'm not trying to be pedantic - just letting other readers know the actual pathophysiology and treatment.

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    4. Tom Hennessy

      Retired

      In reply to Sue Ieraci

      Actually ma'am , I'm too stupid to be pedantic , I fully admit my shortcomings.

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    5. Tom Hennessy

      Retired

      In reply to Sue Ieraci

      "I'm not trying to be pedantic - just letting other readers know the actual pathophysiology and treatment"

      It is BELIEVED by you and others , "actual pathophysiology".
      Rather than try to understand why bloodletting worked in the most dire of cases when nothing else was effective , drugs , you still sing the praises of using drugs instead of simple controlling hemoglobins , which you "were around when it was used".
      One might think the prudent and ethical thing to do would be to revert back to…

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    6. Sue Ieraci

      Public hospital clinician

      In reply to Tom Hennessy

      "or isn't that what you said ?"

      No, it isn't what I said. I said that better treatments have replaced venesection - even in the most severe cases.

      Isn't progress great?

      What is your view of non-invasive ventilation for acute heart failure, Mr Hennessy? (Hint: It can be used no matter what the person's iron level is).

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    7. Tom Hennessy

      Retired

      In reply to Sue Ieraci

      If I recall correctly , you said , morphine replaced venesection , and also you said , venesection was used WHEN morphine no longer worked on the patient , meaning , obviously , venesection was replaced by heroin , and reinstituted when the person no longer 'benefited' by the heroin / morphine ? Venesection , heroin , venesection. NOT , isn't progress great , but just what I said , venesection dropped for drugs and reinstituted when drugs no longer can replace the barbaric life saving venesection.
      As to non-invasive ventilation , the most I know about it is , it destroys the patients vitamin E and leaves them blind due to this 'oversight'.

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    8. Tom Hennessy

      Retired

      In reply to Tom Hennessy

      "Ventilation"
      "Hint: It can be used no matter what the person's iron level is"

      When bloodletting is instituted , the use of ventilation , oxygen use , goes down enough to make those who sell oxygen bottles start to scramble and wonder how they are going to make a living. Evidence based medicine.

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    9. Tom Hennessy

      Retired

      In reply to Sue Ieraci

      They come to you on their last legs , heart failure , and now you ask whether giving them mouth to mouth is a good idea ?

      "In conclusion it may be granted that the immediate results from venesection of 500 c.c. in congestive heart failure are frequently spectacular and in a majority of instances, beneficial. From the very nature of the cases selected for this procedure ultimate recovery is not anticipated in a high proportion. Nevertheless, a survival of 45.4 per cent is reported in this group and an apparent prolongation of life claimed in an added 22.7 per cent (5 cases). The application of such a mechanical therapeutic measure as venesection offers a field of particular usefulness for venous pressure determinations, in that not only does venous hypertension constitute an index of right heart load, but the degree of primary fall in venous pressure on blood-letting and the curve thereafter serve as excellent prognostic measurements of its efficiency."

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    10. Tom Hennessy

      Retired

      In reply to Tom Hennessy

      And now that bloodletting / venesection pulled them from the brink of death , "ultimate recovery is not anticipated " , you can continue in the treatment of their hypervolemia , which will lead , as evidenced below , to zero deaths as opposed to over fifty percent death rate ?

      "This is the largest published study measuring blood volume and patient outcomes. Congestive heart failure is the number one cause for admission to hospitals for patients over 65 years of age and results in annual healthcare…

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