BMJ 1998;317:1125-1130 ( 24 October )

General Practice

Implications of applying widely accepted cholesterol screening and management guidelines to a British adult population: cross sectional study of cardiovascular disease and risk factors

Editorial by Fahey and pp   1120 , 1130 , 1134

Nigel Unwin, senior lecturer, a Richard Thomson, senior lecturer, a Ann Marie O'Byrne, registrar, b Mike Laker, reader, c Heather Armstrong, student. d

a Departments of Medicine and Epidemiology and Public Health, University of Newcastle, Medical School, Newcastle NE2 4HH, b Department of Public Health Medicine, County Durham Health Authority, Durham DH1 5XZ, c Department of Clinical Biochemistry and Metabolic Medicine, University of Newcastle, Newcastle upon Tyne NE2 4HH, d Department of Physiology, University of Sunderland, Sunderland SR1 3SD

Correspondence to: Dr Unwin n.c.unwin{at}ncl.ac.uk

Objective: To compare the implications of four widely used cholesterol screening and treatment guidelines by applying them to a population in the United Kingdom.
Design: Guidelines were applied to population based data from a cross sectional study of cardiovascular disease and risk factors.
Setting: Newcastle upon Tyne, United Kingdom.
Subjects: General population sample (predominantly of European origin) of 322 men and 319 women aged 25-64 years.
Main outcome measures: Proportions recommended for screening and treatment.
Methods: Criteria from the British Hyperlipidaemia Association, the British Drugs and Therapeutics Bulletin (which used the Sheffield table), the European Atherosclerosis Society, and the American national cholesterol education programme were applied to the population.
Results: Proportions recommended for treatment varied appreciably. Based on the British Drugs and Therapeutics Bulletin guidelines, treatment was recommended for 5.3% (95% confidence interval 2.9% to 7.7%) of men and 3.3% (1.5% to 5.3%) of women, while equivalent respective values were 4.6 (2.3 to 6.9) and 2.8 (1.0 to 4.6) for the British Hyperlipidaemia Association, 23% (18.4% to 27.6%) and 10.6% (7.3% to 14.0%) for the European Atherosclerosis Society, and 37.2% (31.9% to 42.5%) and 22.2% (17.6% to 26.8%) for the national cholesterol education programme. Only the British Hyperlipidaemia Association and Drugs and Therapeutics Bulletin guidelines recommend selective screening. Applying British Hyperlipidaemia Association guidelines, from 7.1% (4.3% to 9.9%) of men in level one to 56.7% (51.3% to 62.1%) of men in level three, and from 4.4% (2.1% to 6.7%) of women in level one to 54.4% (48.9% to 59.9%) of women in level three would have been recommended for cholesterol screening. Had the Drugs and Therapeutics Bulletin guidelines been applied, 22.2% (16.5% to 27.9%) of men and 12.2% (8.6% to 15.8%) of women would have been screened.
Conclusions: Without evidence based guidelines, there are problems of variation. A consistent approach needs to be developed and agreed across the United Kingdom.

Key messages

  • Several widely available guidelines give different advice for managing hyperlipidaemia

  • Proportions of the population deemed eligible for screening and treatment can differ considerably between guidelines

  • Even when the proportions eligible for treatment are similar, the individuals often differ

  • There are probably inconsistences in the management of hyperlipidaemia in the United Kingdom

  • Explicitly derived, scientifically valid guidelines that include a consideration of costs are urgently needed



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Rapid Responses:

Read all Rapid Responses

Sheffield table considered economic implications
Lawrence E Ramsay
bmj.com, 5 Nov 1998 [Full text]
One scientifically valid national guideline for the management of hyperlipidaemia is needed
Sudha Bulusu
bmj.com, 10 Nov 1998 [Full text]
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