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LETTERS: Richard Neary, Sud Ramachandran, P N Durrington, Daniel Albert, Dougal Jeffries, and P B S Fowler Risk in cardiovascular disease BMJ 2000; 321: 174 [Full text]

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Risk assessment doesn't impact significantly on prescribing

A F Jones   (20 July 2000)

Risk assessment doesn't impact significantly on prescribing 20 July 2000
A F Jones Send response to journal: Re: Risk assessment doesn't impact significantly on prescribing	EDITOR - The principle of employing a patient's predicted absolute risk of coronary heart disease (CHD) to guide the use of drugs, particularly statins, in primary prevention of the disease, the subject of the BMJ theme issue of 11th March 1, has recently been endorsed by the National Service Framework for CHD. There has been considerable debate about the merit of the various CHD risk prediction methods based on the Framingham equation. We have evaluated and published the performance of all nine of the available risk tables based on the Framingham function in patients selected by their general practitioners. 2 We agree with Durrington 3 that the Sheffield tables, modified to include HDL, and the nomograms published with the joint British societies are most accurate of the tables, with the former being most sensitive and the latter most specific for the 10 year 30% risk level currently considered to be the threshold for statins. Nevertheless, like Durrington, we also believe that computerised calculation of CHD risks is preferable to the use of tables, and argued this case in 1997. 4 In 1998 we introduced a laboratory-based CHD risk calculation system 5 , and have now audited its impact on prescribing decisions in general practice. In 1998, the first year of the laboratory-based system, 1132 CHD risk requests were received from 14 of the 102 practices served by this laboratory. Case notes were reviewed between August and December 1999. Notes could not be found for 133 patients, and a further 99 had recorded pre-existing vascular disease. Of the remaining 906 patients, 81 (8.9%) had calculated 10 year CHD risks ³ 30%, of whom 35 had previously been prescribed a statin. Three more of these high risk patients were prescribed a statin after CHD risk calculation. Of the 43 patients with risks ³ 30% not prescribed statins, 31 (72%) had a serum cholesterol < 6.5 mmol/L, a traditional threshold for the definition of hypercholesterolaemia. Statins had also been given to a further 62 patients with risks < 30%, of whom four had the drug withdrawn after risk calculation. It appears to be assumed that the provision of CHD risk assessment methods will have a significant impact upon prescribing habits. Our data does not support this presumption, even in a group of motivated practices. Implementation of risk-based guidelines, and therefore the NSF for CHD, will require rather more than the provision of risk assessment methods. AF Jones Consultant Chemical Pathologist WA Bartlett Consultant Clinical Scientist Department of Clinical Biochemistry, Birmingham Heartlands Hospital, Birmingham, B9 5SS. FL Game Consultant Physician Department of Diabetes and Endocrinology, Nottingham City Hospital, Hucknall Road, NottinghamNG5 1PB. 1. Risk in cardiovascular disease [theme issue]. BMJ 2000;320 (7236). (11 March). 2. Game FL, Bartlett WA, Walker J, Jones AF Assessment of coronary heart disease risk prediction in general practice: which table? Atherosclerosis 2000;151:276. 3. Durrington PN. Joint British societies recommend their computer program for risk calculation. BMJ 2000;321:174-5. (15 July). 4. Jones AF. Statins and hypercholesterolaemia: UK Standing Medical Advisory Committee guidelines. Lancet 1997;350:1174-5. 5. Bayly GR, Bartlett WA, Davies PH, Husband D, Haddon A, Game FL, et al. Laboratory-based calculation of coronary heart disease risk in a hospital diabetes clinic. Diabet Med 1999: 697-701.