Cardiovascular disease risk assessment and reduction: summary of updated NICE guidance
BMJ 2023; 381 doi: https://doi.org/10.1136/bmj.p1028 (Published 26 May 2023) Cite this as: BMJ 2023;381:p1028
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Dear Editor
This guidance appears to be directed at primary care clinicians: GPs, Nurses and pharmacists. It is a pity that the guideline committee could not find space for a primary care clinician as a member. If they had done so, the issues raised by Muir Gray and GPs in these responses could have been addressed before the guidelines were published. They might also have been made aware of the excellent article you published recently entitled "Guidelines should consider clinicians’ time needed to treat".
https://www.bmj.com/content/380/bmj-2022-072953
Competing interests: No competing interests
Dear Editor
I'm sorry to see that this article and the NICE guidance upon which it is based seems stuck on the lipid hypothesis as a major causative agent in cardiovascular disease, entirely ignoring the role of sugar and fructose in particular. John Yudkin's 1972 book 'Pure White and Deadly' presented cogent evidence of its importance, as well as the role of the sugar industry in suppressing sugar's role in favour of the lipid hypothesis.
Despite statins being among the largest selling drugs of all time, the evidence of benefit seems limited to secondary protection, and to primary protection but only in patients with very high cholesterols aged less than 60. Thomas Hager book 'Ten Drugs' gives the clearest summary I have read of the risk-benefit balance for statins in preventing cardiovascular disease.
I hope that NICE will soon take account of the volume of research in the sugar field, and will continue to examine whether statins have any general benefit in primary protection.
As a vascular surgeon, I believe that a main benefit of statins is in reducing arterial inflammation, but this is rarely mentioned in the literature
Competing interests: No competing interests
Dear Editor
The authors write that qrisk estimates the CVD (cardiovascular disease) risk. Regrettably they do not define CVD. This is a missed opportunity because there seems to be remarkable lack of agreement between apparently credible sources.
A patient wishing to understand a qrisk result might look up “cardiovascular disease” on NHS.net (1). They will find a definition encompassing coronary heart disease, stroke, TIA, peripheral artery disease and aortic aneurysm. NHS England adds congenital heart disease and vascular dementia to the list (2).
Perhaps the official qrisk website (3) is a better place to start. Its homepage reports that qrisk measures the risk of "heart attack and stroke" alone. This minimalist claim is also found in Public Health England's document " Qrisk3 Explained" (4), and the British Heart Foundation’s website (5) as well as numerous GP practice websites.
Perplexingly, if our patient navigates to the "about" page of the qrisk website, they will find a claim that contradicts its homepage: the claim that qrisk measures the risk of "stroke, transient ischaemic attack, myocardial infarction or angina". This definition also appears on numerous GP practice websites.
A fifth variation appears in NICE patient information (6) and elsewhere on the NHS website (7): apparently qrisk measures “heart disease and stroke”, but TIA is not mentioned.
Finally the review article under discussion presents a further conundrum: while the body of the text says that qrisk estimates CVD risk, the “what you need to know” box says rather that it estimates the risk of a “CVD event”. A “CVD event” is not defined here. An online search for “cardiovascular event” produces conflicting definitions whose elements include: myocardial infarction, stroke (though I did not find TIA mentioned), angina, heart failure and venous thromboembolism.
It seems there is an urgent need to bring clarity and consistency to explanations of what qrisk is measuring. Clinicians will struggle to offer informed choice to our patients amidst the welter of contradictory explanations currently on offer.
1) https://www.nhs.uk/conditions/cardiovascular-disease/
2) https://www.england.nhs.uk/ourwork/clinical-policy/cvd/
3) qrisk.org
4) https://www.healthcheck.nhs.uk/seecmsfile/?id=1687
5) https://www.bhf.org.uk/informationsupport/heart-matters-magazine/medical...
6) https://www.nice.org.uk/guidance/cg181/resources/patient-decision-aid-pd...
7) https://www.nhs.uk/conditions/nhs-health-check/what-happens-at-an-nhs-he...
Competing interests: No competing interests
Dear Editor
As always, wonderfully clear but how will it be put into practice when one considers the load that primary care is already under? Here are 4,270 more words to take in and act on when GPs and practice nurses are already under the pressure so eloquently described by Helen Salisbury and Rammya Matthew (1,2) . The answer is that citizens, the people called patients, need to take action and they need the knowledge and encouragement to do so, personalised to take into account their health condition, and where they live, all of which is available on their GP record.
Muir
Sir Muir Gray
1 Salisbury H (2023). Fictive schedules and the unbearable load of general practice. BMJ 381;1038
2. Matthew R (2023). Helping patients off the conveyor belt of interventions.BMJ 381; 761
Competing interests: i am working of the development of a Digital Therapeutic Community so that citizens can take responsibility for selfceare
Dear Editor
a 65-year-old white male, who is a non-smoker and does not have any of the following conditions: diabetes, angina or heart attack history, chronic kidney disease, atrial fibrillation, blood pressure treatment, migraines, rheumatoid arthritis, systemic lupus erythematosus, severe mental illness, atypical antipsychotic medication, regular steroid tablet use, or a diagnosis or treatment for erectile dysfunction, and has a cholesterol/HDL ratio of 3.4, a standard deviation of at least 10 mmHg in the two most recent systolic blood pressure readings, and a normal body mass index, has a 10-year QRISK3 score of 11.5%. This means that out of a group of 100 people with the same risk factors, approximately 11.5 individuals are likely to experience a heart attack or stroke within the next 10 years. These findings are discouraging for individuals in optimal health.
However, if the same individual engages in regular physical activity (1), resides in an area with good air quality (2), reduces its salt intake (3), follows a Mediterranean diet (4), abstains from alcohol consumption (5), and has a discrepancy of less than 5 points in systolic blood pressure between their arms (6), its 10-year risk of experiencing a heart attack or stroke could potentially decrease. Taking these factors into account could encourage individuals to adhere more closely to NICE recommendations, as adopting these lifestyle modifications could contribute to a reduction in their 10-year risk of developing cardiovascular disease.
1. Huang, WC., Tung, CL., Yang, YC.S.H. et al. Endurance exercise ameliorates Western diet–induced atherosclerosis through modulation of microbiota and its metabolites. Sci Rep 12, 3612 (2022). https://doi.org/10.1038/s41598-022-07317-x
2. de Bont J, Jaganathan S, Dahlquist M, Persson Å, Stafoggia M, Ljungman P. Ambient air pollution and cardiovascular diseases: An umbrella review of systematic reviews and meta-analyses. J Intern Med. 2022 Jun;291(6):779-800. doi: 10.1111/joim.13467. Epub 2022 Mar 8. PMID: 35138681; PMCID: PMC9310863.
3. Wuopio J, Ling YT, Orho-Melander M, Engström G, Ärnlöv J. The association between sodium intake and coronary and carotid atherosclerosis in the general Swedish population. Eur Heart J Open. 2023 Mar 30;3(2):oead024. doi: 10.1093/ehjopen/oead024. PMID: 37006408; PMCID: PMC10063371.
4. Jimenez-Torres J, Alcalá-Diaz JF, Torres-Peña JD, Gutierrez-Mariscal FM, Leon-Acuña A, et al. Mediterranean Diet Reduces Atherosclerosis Progression in Coronary Heart Disease: An Analysis of the CORDIOPREV Randomized Controlled Trial. Stroke. 2021 Nov;52(11):3440-3449. doi: 10.1161/STROKEAHA.120.033214. Epub 2021 Aug 10. Erratum in: Stroke. 2021 Nov;52(11):e754. PMID: 34372670.
5. Laguzzi, F., Baldassarre, D., Veglia, F. et al. Alcohol consumption in relation to carotid subclinical atherosclerosis and its progression: results from a European longitudinal multicentre study. Eur J Nutr 60, 123–134 (2021). https://doi.org/10.1007/s00394-020-02220-5C. Clark, J. Berger. Hypertension, Dec. 21, 2020, online.
6. Clark CE, Warren FC, Boddy K, McDonagh STJ, Moore SF, et al. Associations Between Systolic Interarm Differences in Blood Pressure and Cardiovascular Disease Outcomes and Mortality: Individual Participant Data Meta-Analysis, Development and Validation of a Prognostic Algorithm: The INTERPRESS-IPD Collaboration. Hypertension. 2021 Feb;77(2):650-661. doi: 10.1161/HYPERTENSIONAHA.120.15997. Epub 2020 Dec 21. PMID: 33342236; PMCID: PMC7803446.
Competing interests: No competing interests
Dear Editor
As a GP I regularly spend 20 minutes wading through treacle in one of our 10 minute appointment slots to discuss cholesterol, usually under the problem heading "NHS Health Check Completed". I contributed to the call for contributions on this guideline from NICE that the QRISK 10 year calculators put every man over 60 and every woman over 70 at a >10% CV risk, and therefore testing for cholesterol or discussing NICE guidelines in these age groups is a waste of time and resources and the guidelines might as well recommend statins for anyone of this age. Cholesterol is a genetic setting so repeatedly retesting also appears wasteful to me.
It is disappointing to see the guidelines recommend assuming everyone over 85 is at risk of disease or death (apologies to all of that age to burst their bubble), and to consider how many minutes in disease free survival could be achieved by starting someone of 85 on statins, while they were at no risk for the previous 84 years and 364 days if they managed to evade cholesterol testing until then.
I find myself at the age of 62 at a risk of 9-16% percent depending on which health conditions are declared, with parents in their 90s who had a long smoking history but no CV disease. I consider myself at low risk having only a 25 year smoking history, and had always declined cholesterol screening as a waste of NHS resources. It was however included in a recent blood test and I am now burdened with knowing my total cholesterol is dangerously raised at 5.2 (<5.0) and my LDL at 3.2 (<3.0). Time for a wasteful 20 minute consultation to add to NHS expenditure? Feed the figures into the calculator in two years age 64 to find out my risk has risen from 8.6% to the magical 10%? Expose myself for another two years to my harmful cholesterol levels before starting statins?
https://www.bmj.com/content/381/bmj.p1028
https://www.qrisk.org/index.php
https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.116.021407
Competing interests: No competing interests
Re: Cardiovascular disease risk assessment and reduction: summary of updated NICE guidance
Dear Editor
How disappointing, in this day of overmedicalisation that the NICE committee do not have the nerve to employ common sense when suggesting discussions with those over 85 on starting statins. I wonder if the cost, environmental impact, benefits of deprescribing, strength of evidence, time for such discussions and....heaven forbid....the actual evidence base....were considered? A 466 page document does not negate the application of sensible medicine. The suggestion seems more to avoid accusations of being ageist than any practical, real world benefit. The idea of taking action to protect yourself against criticism, blame, etc, comes to mind. No wonder costs are spiralling with such spineless guidance.
Dr Hamish Duncan
GP
Exeter
Competing interests: No competing interests