Letters

National service framework for coronary heart disease

BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7261.634 (Published 09 September 2000) Cite this as: BMJ 2000;321:634

Ambiguities need to be clarified

  1. Roger Lloyd-Mostyn, consultant physician
  1. King's Mill Centre, Sutton-in-Ashfield, Nottinghamshire NG17 4JL
  2. Killamarsh Medical Practice, Sheffield S21 4DJ
  3. University of Birmingham, Birmingham B15 2TT
  4. University Department of Medicine, City Hospital, Birmingham B18 7QH

    EDITOR—One of the priorities in the national service framework for coronary heart disease summarised by Mayor1 was “improved use of effective medicines after heart attack—especially aspirin, β blockers, and statins—so that 80-90% of people discharged from hospital after a heart attack will be prescribed these drugs.” This is the recommendation in the executive summary, which taken at face value implies that all three drugs should be prescribed before a patient leaves hospital. In contrast, the recommendation in the main document is that aspirin and β blocker treatment should be started in hospital and statin treatment left for “continuing care.”

    Statin treatment was not started at the time of infarction in any of the large secondary prevention studies. The shortest times from infarction to inclusion were six months in the Scandinavian simvastatin survival study (4S),2 and three months in the cholesterol and recurrent events (CARE) study3 and the long term intervention with pravastatin in ischaemic disease (LIPID) study.4 Thus the common practice of starting treatment before discharge is not strictly evidence based and statin treatment may be harmful immediately after myocardial infarction. Starting treatment before discharge, however, ensures that the drug is prescribed and simplifies audit.

    A further recommendation in the main document is “give statins to lower serum cholesterol concentrations either to less than 5 mmol/l (low density lipoprotein cholesterol …

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