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Jun 02, 2010


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Great points, and these surrogacy issues are really fundamental to the practice of American style medicine. Even in my acutely hospitalized patients, many treatment decisions are based on managing surrogate markers for which the impact on meaningful clinical outcomes is nebulous at best. LDL < 70, inpatient SBP < 130, glucose 70-120 all take on a clinical life of there own; the patient is diseased because we say so. Does the CAD patient with an LDL of 101 really have dyslipidemia (he's not at goal!) And once you start adding these "diseases" to your problem list- we've created a meta-reality that just might often be divorced from the real reality of disease, suffering, benefit and harm.

What really annoyed me is some of the stories in the media saying that no increased cardiac risk was apparent with a lower dose of Avandia. Well, of course not! The trial was never big enough to determine that in the first place.

Response to Joseph Nicolas MD MPH.
I agree, all surrogate markers.
If we follow atherosclerosis as a biological disease without waiting for clinical events to occur or recur, but with some form of highly sensitive atheroma imaging, we don't have to rely on upstream surrogates like LDL, SBP, and glucose at all.

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