Endgames Case Review

Assessment of cardiovascular risk in primary care

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i3022 (Published 13 June 2016) Cite this as: BMJ 2016;353:i3022
  1. Salman Waqar, honorary clinical fellow1,
  2. Faraz Mughal, general practitioner and honorary research fellow2,
  3. Ahmed Rashid, National Institute for Health Research academic clinical fellow3,
  4. Jonathan Mant, professor primary care research3
  1. 1Department of Public Health and Primary Care, Imperial College London W6 8RP, UK
  2. 2Warwick Primary Care, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
  3. 3Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
  1. Correspondence to: S Waqar s.waqar{at}imperial.ac.uk

A 41 year old white man presented to his general practitioner for a routine blood pressure check. He was asymptomatic and had an initial reading of 154/115 mm Hg. Subsequent ambulatory blood pressure monitoring (ABPM) showed that the average daytime reading was 137/89 mm Hg.

On further assessment he had no evidence of left ventricular hypertrophy on electrocardiography, and no silver wiring or other abnormalities were found on funduscopy. Laboratory tests showed total cholesterol 6.8 mmol/L (reference range <5 mmol/L), triglycerides 5.9 mmol/L (0.45-1.69), high density lipoprotein (HDL)-cholesterol 0.76 mmol/L (>1). There was no evidence of urinary microalbuminuria.

He drank a moderate amount of alcohol at weekends only and smoked 10 cigarettes a day. He had a medical history of depression and dyspepsia for which he took sertraline and omeprazole daily. He had no family history of cardiovascular disease (CVD).

His QRISK2 score was calculated as 10.3%. He was worried about what this meant for his health and wanted help in making decisions about how to proceed.

Questions

  1. Which guidelines and tools could help facilitate a discussion that leads to shared decision making with the patient?

  2. What are the important principles of lifestyle advice to deliver?

  3. Is drug treatment indicated in this patient?

  4. When is referral to secondary care warranted?

Answers

1. Which guidelines and tools could help facilitate a discussion that leads to shared decision making with the patient?

Short answer

The National Institute for Health and Care Excellence (NICE) has developed a clinical guideline (CG181) on lipid modification for primary and secondary prevention of CVD.1 Patient decision aids present evidence based estimates of the risks and benefits of treatment options to help facilitate shared patient focused decision making.

Discussion

The NICE guideline offers evidence based advice and recommendations on the treatment of people currently with, or at risk of, CVD. International guidelines from the European Society of Cardiology (ESC) and the American College of Cardiology (ACC) also provide robust guidance tailored …

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