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GPs go forth

Patients at 10% risk shun offer of statin from their GP

Only a tenth of patients with a 10-20% predicted risk of cardiovascular disease chose to take a statin when given the opportunity, a study by GPs has revealed.

A practice in Cambridgeshire invited more than 400 patients who had previously attended an NHS Health Check appointment and had a QRISK2 score of between 10% and 20% to come in for an appointment at a specially arranged clinic to discuss starting statins.

Of 410 patients invited, just 100 (24.4%) attended the clinic – and only 45 (11%) started on a statin.

The GPs – who have now published their findings in the International Journal of Clinical Practice – said this suggested people at relatively low risk of cardiovascular disease were less inclined to start statin therapy than NICE experts had expected.

NICE predicted that only 20% of patients at 10-20% risk would refuse the offer of statins when it released its updated lipid modification guidelines last year.

However, a Pulse investigation showed GPs’ prescribing of statins had barely changed since NICE’s lowered threshold was introduced last summer – suggesting GPs were reluctant to push wider statin on the low-risk population.

And the latest study suggests that low-risk patients are equally reticent about taking statins.

The Firs House Surgery sent the patients an information leaflet along with their invite, which provided information on the new NICE recommendation, the way risk is calculated and what the benefits and harms of statins are – based on the National Prescribing Centre Statins Patient Decision aid.

The GPs found:

  • Older people and those with a higher QRISK Score within the 10-20% range were more likely to end up taking a statin;
  • Both ex- and current smokers were more likely to start a statin than non-smokers
  • Patients who opted not to start treatment most commonly cited preferring to initially try lifestyle changes as the main reasons;
  • Concern about side effects was less commonly reported.

One of the GPs, Dr Simon Poole, GPC member and chair of Cambridgeshire LMC - who is an outspoken critic of statins at the lower risk level - stressed to Pulse the information given to patients about the option to take statins was ‘neutral’.

Dr Poole said: ‘Simply asserting that doctors are failing patients because statin prescriptions for low risk patients have not soared following the new NICE guidance, or proposing to use incentives to increase statin prescriptions, ignores the voice of the individual patient and their right to determine their own treatment.’

Dr Andrew Green, chair of the GPC’s clinical prescribing subcommittee said the study ‘will fit in with the clinical experience of many GPs’.

Dr Julian Treadwell, vice-chair of the RCGP’s standing group of over-diagnosis, said it was ‘a fascinating small study’ with the result showing low uptake among patients ‘after receiving well balanced information’.

However, Dr Treadwell cautioned that the study was done ‘in just one practice in a relatively affluent area so we must be cautious about applying the result to the whole population’.

A NICE spokesperson responded: ’The NICE guidance is very clear: it is only after lifestyle changes are considered first, followed by other risk factors such as hypertension, that people who are at risk should be offered the opportunity to use a statin, if they want to.

‘They don’t have to, and indeed the authors of this study identify the most common reason for not starting a statin in the study were either not wanting to take medication or preferring to initially change their lifestyle.’

They added that the results of this study ‘should be interpreted with caution’.

Int J Clin Prac 2015; available online 30 Sept

Readers' comments (5)

  • It would be interesting to see how many who preferred 'lifestyle change' actually did it in a year's time.

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  • Samuel Lewis

    So what's the problem with NICE guidance? Why did GPs get so hot under the collar when the Firs practice did it all for the good of science ?

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  • Recently it has been suggested that migraine with aura is an additional risk factor that takes the CV risk over 10% in a proportion of patients, and that therefore you should take statins. It seems more scientific to me to prevent the migraine attacks! Low-dose aspiring will do this.

    In any event there is growing evidence that the relationship of risk, cholesterol and statins may have nothing to do with the cholesterol, but that statins work by some as yet unclear anti-inflammatory mechanism. We should remember that the initial research on cholesterol by Ancel Keyes (on which the whole statin edifice has been constructed) has been shown to have serious flaws. Also it's been shown that the number of prevented strokes or coronaries per prescription of statins is pretty low. And lastly a relative risk reduction of 50% means an absolute reduction of only 5% if the initial absolute risk is 10% - barely statistically significant.

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  • Vinci Ho

    (1) Prevention based on statistics is strictly speaking , only 'pure' science to me. ''I offer you statin because of your 10% chance of having a heart attack or stroke next ten years(since we already try 3-6 months lifestyle changes), although I understand you have never been on regular medication.'' In a way, this sounds like the insurance company advisor trying hard to sell me a life insurance policy product with his risk calculator .
    (2) Yet this was the original plan of NICE setting up GPs to earn corresponding QOF points. There is indeed good practice to have a good conversation with a patient about his/her 10 years CVD risk and offer options with lifestyle changes as first choice and statin second . If the patient declines , invite back 12 months later to re-score again(as per the NICE guidance)
    (3) But this 10 year CVD risk score will only be meaningful if there is a 'carpet' (NOT opportunistic)screening of all at age between 40-74 and bear in mind all otherwise healthy 75 years old or above should be all on statin as their CVD risk scores are above 20%. The GP workload entailed required for this is enormous and is clearly not 'affordable' in NHS with the current level of resources in primary care. I used the same argument of carpet screening in the debate about dementia screening. Perhaps , it will be 'perfect' if so many patients will take statin everyday and reduce their chance of MI/Stroke by one third .Hence, so many lives can be saved and so much money can be saved for health economics.
    (4) Then you still have interesting questions like' What if I still develop a heart attack taking statin everyday?' OR ' Will I certainly have a heart attack if I don't take it?' These are voices coming from ground zero earth , not high up in the tower. To me , using statin for primary prevention at 10% CVD risk is never comparable to vaccination for infectious diseases (MMR , meningitis , hepatitis B etc). Even so, the public still have a lot of doubts about the latter from time to time.
    (5) I do not, for a second, question the fact there are abundant evidences of statin in both CVD primary and secondary prevention , particularly the latter ,as well as this debate is no longer about the conspiracy of drug companies pushing statin.But evidence based medicine (EBM) is not perfect and in a way , a 'religion' to me . Then , the evidence of accepting and believing certain EBM is another level of the religion from a philosophical point of view.
    (6) Last but not the least , I still yet to see a confident statement about the probability ( not possibility ) of side effects particularly non CK elevated myalgia (nCKEM) -5%,10% or 15%??

    As we remember from our teachings in medical school and GP training, individualised medicine is way different from treating the 'crowd' . The art of practising the former with continuity makes the job of general practitioner so unique...........

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  • There's more to life than a statin.

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