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BMJ No 7122 Volume 315 Letters Saturday 13 December 1997
Use of statinsSee Editorial by Muldoon p 1554Standing Medical Advisory Committee should reconsider advice to use Sheffield risk tableEditorThe Standing Medical Advisory Committee's guidelines for primary and secondary prevention of vascular disease and treatment of hyperlipidaemia(1) recommend that primary prevention should be governed by the Sheffield risk table propounded by Ramsey et al.(2) As clinicians running many of the United Kingdom's specialist cardiovascular or lipid clinics, we are pleased that the Department of Health has finally accepted the overwhelming evidence that cholesterol lowering is essential. We wish, however, to express our concern about the guidelines: The Sheffield risk table is based on an arbitrarily high risk of coronary heart disease of 30% over 10 years; this is contrary to established international opinion, which sets a threshold of risk of 15-20% (European Society of Cardiology/European Atherosclerosis Society /European Society of Hypertension; American Heart Association; New Zealand Medical Society). Additionally, the table dismisses many important risk factors and their varying severity by relegating them to footnotes.(3) These risk factors include the high frequency of familial hyperlipidaemias (1 in 200 to 1 in 500) and the effect of family history; the influence of ethnic origin, particularly in Asians; and the effect of high density lipoprotein and triglyceride concentrations. The table thus ignores the poor prognoses associated with these risk factors and the need for early treatment in patients with them. Unfortunately, doctors will probably use the table to avoid cholesterol testing in younger patients without noting the 'small print.' This will ensure that primary prevention is not offered to patients who would benefit. Such patients would only receive secondary prevention, after irreparable damage had been allowed to occur. Secondary prevention can be defined as 'primary prevention that has occurred too late.' Thus use of the Sheffield risk table could be considered to be state sponsored negligent practice. We urge the Standing Medical Advisory Committee to reconsider its advice to use the Sheffield risk table. We urge clinicians to continue to use other, more appropriate and more widely recognised, guidelines on lipid treatment, such as those published by the British Hyperlipidaemia Association(4) or the European societies.(5) Signed by 103 professors, consultants, and specialists in preventive cardiology, chemical pathology, metabolism and lipids, clinical pharmacology, epidemiology, and public health from England, Wales, and Northern Ireland
Correspondence to Dr T M Reynolds, References
1 NHS Executive. SMAC statement on use of statins.
Wetherby, West Yorkshire: Department of Health, 1997.
(Executive letter EL(97)41.)
2 Ramsey L, Haq I, Jackson R, Yeo W. The Sheffield table for
primary prevention of coronary heart disease. Lancet
1996;348:387-8, 1251-2.
3 Tunstall-Pedoe H, Woodward M, Tavendale R, A'Brook R, McCluskey
M. Comparison of the prediction by 27 different factors of coronary
heart disease and death in men and women of the Scottish heart study:
cohort study. BMJ 1997;315:722-9. (20 September.)
4 Betteridge D, Dodson P, Durrington P, Hughes E, Laker M,
Nicholls D, et al. Management of hyperlipidaemia:
guidelines of the British Hyperlipidaemia Association. Postgrad
Med J 1993;69:359-69.
5 Pyorala K, De Backer G, Graham I, Poole-Wilson P, Wood D on
behalf of the task force. Prevention of coronary heart disease in
clinical practice: recommendations of the task force of the European
Society of Cardiology, European Atherosclerosis Society and European
Society of Hypertension. Eur Heart J
1994;15:1300-31.
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