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LETTERS: Roger Lloyd-Mostyn, Paul Cracknell, Kate Jolly, Andrew Rouse, and Greg Y H Lip National service framework for coronary heart disease BMJ 2000; 321: 634 [Full text]

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National Service Framework for CHD

Roger Boyle   (27 September 2000)

More confusion !

L S Lewis   (19 August 2001)

National Service Framework for CHD 27 September 2000
Roger Boyle, National Director for Heart Disease Department of Health Send response to journal: Re: National Service Framework for CHD	Lloyd-Mostyn [1] and Cracknell [2] raise concerns about the recommendation in the National Service Framework for Coronary Heart Disease [3] to reduce cholesterol concentration by 30%. May I clarify the Department's position. The wording of the advice on cholesterol lowering in the NSF was intended to read: 'Statin therapy should aim to lower cholesterol below 5.0 mmol/l or to reduce total serum cholesterol by 20-25%, whichever would result in the lowest level. Equivalent figures for LDL cholesterol would be 3.0 mmol/l or by 30% reduction, whichever results in the lowest level'. This is consistent with the Joint British recommendations [4] On the matter of when to start statin therapy following acute myocardial infarction, the Joint British recommendations [4] state that 'Patients admitted with unstable angina or acute MI…should …be prescribed lipid lowering therapy before discharge…' It was our intention to incorporate this professional consensus on treatment into the Framework. Jolly and colleagues [5] suggest that many operators and facilities will not meet the standards set out in the NSF for number of procedures performed. As with statins, the advice in the NSF is consistent with that published by the professions. [6] The key point is that the NSF sets out a 10 year programme for improving cardiac services, which will mean that more procedures will be undertaken than ever before, backed up by a substantial investment package. An important consequence of the NSF is the opportunity it now provides to bolster the NHS capacity to treat heart disease, alongside our wider effort to reduce mortality through the new national standards for prevention, treatment and rehabilitation of coronary disease. Yours faithfully, Dr Roger Boyle National Director for Heart Disease Department of Health References 1. Lloyd-Mostyn R. Ambiguities need to be clarified. BMJ 2000;321:634 2. Cracknell P. Target of lowering cholesterol by 30% needs to be justified. BMJ 2000;321:634 3. Department of Health. National service framework for coronary heart disease. www.doh.go.uk/nsf/coronary 4. Wood D, Durrington P, Poulter N, McInnes G, Rees A, Wray R on behalf of the British Cardiac Society, British Hyperlipidaemia Society, British Hypertension Society and endorsed by the British Diabetic Association. Joint British recommendations on prevention of coronary heart disease in clinic practice. Heart 1998;80 (Suppl): S1-29 5. Jolly K, Rouse A, Lip GYH. Many operators and facilities will not meet standards set out in framework. BMJ 2000;321:634 6. Joint Working Group on Coronary Angioplasty of the British Cardiac Society and British Cardiovascular Intervention Society. Coronary angioplasty: guidelines for good practice and training. Heart 2000;83:224- 235
More confusion ! 19 August 2001
L S Lewis, GP Surgery, Newport, Dyfed Send response to journal: Re: More confusion !	The original Coronary NSF Cholesterol-lowering Objective was confusing enough:- 'statins and dietary advice to lower serum cholesterol*** concentrations EITHER to less than 5 mmol/l (LDL-C to below 3 mmol) OR by 30% (whichever is greater)' It does indeed say ‘whichever is the greater’, was and is a confusing and poor use of English !! But Dr Roger Boyle adds to the absurdity with his attempted clarification:- 'Statin therapy should aim to lower cholesterol below 5.0 mmol/l or to reduce total serum cholesterol by 20-25%, whichever would result in the lowest level. Equivalent figures for LDL cholesterol would be 3.0 mmol/l or by 30% reduction, whichever results in the lowest level'. To interpret the Objective as literally suggested will mean that NO starting cholesterol is low enough, and ALL will need at least 20-25% lowering.. (guaranteeing a Statin in every case). This leads to the absurdity of starting treatment in a patient with total cholesterol of 3 or 4. My reading of the referenced BMJ Editorial ‘Cholesterol: How low is low enough’ suggests that only average or high Cholesterols are intended for treatment, to achieve either 5mmol/L (or LDL less than 3.0mmol/L) or at least 30% reduction if < 5mmol/l cannot be achieved (eg starting cholesterol = 12 ). 4S and CARE confirm that benefits are related directly to LDL reductions achieved, and do not accrue if starting LDL is below 3.00mmol/L. (A target total cholesterol of 3mmol/L is absurd, at least on present evidence). Am I wrong ? Further clarification is urgently needed !