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GPs go forth

GPs face major drive to put younger patients on statins as JBS recommends lifetime QRisk score

Exclusive GPs face a major upheaval to the way they assess patients for statin treatment, after the Joint British Societies decided to ditch 10-year risk prediction in favour of the QRisk Lifetime Score.

Pulse has learnt that the influential guideline group is about to herald a paradigm shift in primary prevention by announcing a switch to a model derived from the QRisk lifetime score, in a decision that is likely to heavily influence an ongoing review of NICE guidelines on risk prediction for cardiovascular disease.

Proponents of the lifetime risk score argue that it will allow much earlier preventative intervention in younger patients who fall below conventional 10-year high-risk thresholds because of their age. But others - including the lead researcher behind QRisk - argue the change will confuse GPs and potentially lead to overtreatment of younger people.

Pulse revealed in 2011 that the JBS3 guideline was likely to recommend lifetime risk in place of 10-year risk scoring for cardiovascular disease, and that it had delayed publication of its guidance to allow its messages to be aligned with those of NICE.

Like QRisk2, the QRisk lifetime score is developed from UK primary care data and takes into account wider cardiovascular risk factors such as ethnicity, social deprivation, rheumatoid arthritis and family history as well as the classic risk factors. However, it calculates an individual’s risk over their remaining lifetime rather than over the next 10 years, identifying those who would not be flagged up using a 10-year risk score.

A statement from the JBS group on its website reveals that the guideline is now in ‘the final stages of development’ and will recommend a new lifetime risk calculator, which will be based on the QRisk lifetime score, the chair of the JBS3 guideline group has told Pulse.

The statement says: ‘The JBS3 will focus on the idea of lifetime prevention, moving away from the 10-year risk model used in JBS2.

‘The JBS3 will include a risk calculator for practitioners to use with patients, which will illustrate the risk of cardiovascular disease and the benefits that can be gained by interventions. This risk calculator will be freely accessible on this website, once the JBS3 has been launched.’

NICE is currently revising its cardiovascular risk prevention guidance, although the institute would not be drawn on whether it was currently considering introducing lifetime risk prediction.

Dr Terry McCormack, a GP in Whitby and editor of the British Journal of Cardiology, said many people in their 40s die of their first heart attack, and it made ‘perfect sense’ to target them earlier by using lifetime risk.

He said: ‘We try to prevent atheromatous disease too late. Preventative therapy is all about starting early. We are all very happy to vaccinate against cervical cancer in teenage girls. Why not tackle heart disease earlier?

‘This is about finding the highest risk patients early and starting treatment to prevent death at an early age. Anyone dying of an myocardial infarction in their 40s or 50s is a tragedy.’

But others are less convinced. Professor Julia Hippisley-Cox, a GP in Nottingham and the researcher whose team developed the QRisk Lifetime Score, said that there was a real risk that GPs would be confused about how to apply the new score.

Professor Hippisley-Cox told Pulse: ‘Our view is that the risks/benefits of adopting a lifetime approach are yet to be established. It probably won’t improve things and may make it much more complex for GPs, risking the progressive implementation of primary prevention.’

She added: ‘The concern is that it could cause confusion amongst primary care staff as lifetime risk is a different concept from 10-year risk.’

Dr Tom Marshall, reader in primary care at the University of Birmingham who worked on the economic case for the 2008 NICE guidelines on lipid modification, said there was no evidence that earlier treatment had any benefit.

He said: ‘If you’re at risk of heart disease, but most of that risk happens when you’re over 60, then the preventive activities should happen when you’re over 60, because that’s when you’ll actually get some benefit from it, whereas taking treatments between the ages of 30 and 60 will be of very little benefit to you.

‘We’ve got no evidence to suggest that taking treatments between 30 and 60 will reduce your risk after the age of 60.’

A spokesperson from NICE said: ‘I’m afraid I’m not able to reveal any specifics at this time as to whether we are looking at this tool.’

Readers' comments (9)

  • and of course our prescribing budgets will be uplifted to accommodate this.............................

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  • The baseline data seems to
    be statistical soup derived from retrospective trawling of variably recorded primary care computer notes.
    Primary prevention trial data is largely absent. Now that statins are generic the drugs will cost less than the monitoring and diagnosis and treatment of side effects.
    The principles guiding NICE and the 2004 QOF was evidenced based action. A decade on and we are back to Mickey Mouse .

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  • I can understand if the risk is calculated for a longer period but not lifetime.
    I have a new risk score which is easy to calculate and be administered by anyone. Its called lifetime risk of death.
    Incidentally it happens to be 100% (all death is certain).
    If no should die of cardiovascular cause what should they die of ? UTI

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  • I doubt that it will make much difference - apart from causing confusion! If you want to avoid MI deaths in the 40's and 50's screen for FH and continue to improve the treatment of diabetics - Simples!

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  • What irritates me the most about the guideline makers is their pretence that they come across a magic pill that we all SHOULD be prescribing.Wouldn't it be more honest of them if they said that "look folks we're really desperate to have a drug that stablises atheromatous plaques,that cuts the risk of acute coronary events down to zero but because there is no such thing at present we suggest that you MAY wish to try a statin in the high risk groups bearing in mind that there is no primary prevention trial date for its efficacy"

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  • Any "guideline" (should really be called diktat) that advocates primary prevention on such a scale,without any harm vs benefit clinical trial data to back it ,should first be subject to a judicial review before being authorised.Trial evidence has to be of high quality.Extrapolations and other statistical shenanigans won't do.To quote the great Carl Sagan:
    "Extraordinary claims require extraordinary evidence"

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  • Vinci Ho

    Common sense
    Are we absolutely clear we are not suffering from SOS , statin obsessive syndrome ?
    Have we taken patient's feelings into account ?

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  • I love the Carl Sagan quote!
    Do we know who is to benefit from wider statin prescribing? Usually, the answer is easy.......pharmaceutical companies. Expand the market is one strategy to increase sales.
    Patients' feelings will be taken into account......after they develop side effects or need switching because of interactions........

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  • Worth pointing out that most statins are off patent now, so not much in the way of Big Pharma profits to be made here. NHS price for Simvastatin 40mg x 28 is currently £1.24 and Atorvastatin 20mg x 28 is £1.60.

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