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NICE set to make dramatic u-turn on lipids guidance

By Nigel Praities

NICE is set to perform a dramatic u-turn in its long-awaited lipid modification guidance, reversing its controversial decision to introduce a new UK-based risk score for cardiovascular disease.

The backtracking follows a major row between experts over the validity of the QRISK assessment system – developed in general practice – and a powerful rearguard action in defence of the much-maligned Framingham charts.

The institute's final guidance on lipid modification, due next week, is now expected to recommend GPs assess cardiovascular risk by a version of Framingham modified by ethnicity and family history. A draft document in February had opted for QRISK.

The move will spare GPs a massive reconfiguration of computer systems and avoid major changes to existing practice. But the recommendation goes against the advice of three international experts commissioned by NICE, who independently ruled QRISK had ‘better discrimination' in a UK population.

NICE will advise GPs multiply Framingham risk by 1.5 in a patient who has one first-degree relative with a history of premature heart disease, and by 1.4 for south Asian men. But unlike QRISK, the system will not adjust for deprivation.

Professor Julia Hippisley-Cox, QRISK researcher and professor of primary care at the University of Nottingham, questioned what new evidence had emerged to change the institute's mind. She said: ‘Can NICE publish its equity impact assessment and if it hasn't done one why not? Does it have any worries about widening health inequalities in our most disadvantaged communities?'

Dr Tom Marshall, a member of the guideline development group and senior lecturer in public health at the University of Birmingham, said after looking closely at the evidence the group had decided it was too early to recommend QRISK. ‘Framingham has been around for a long time and people are familiar with it,' he said.

Dr Marshall said it was ‘quite likely' another equation would replace Framingham in future, but it was not clear if this would be QRISK.

Cardiovascular specialists welcomed the change of heart. Professor Neil Poulter, professor of preventive cardiovascular medicine at the National Heart and Lung Institute and an author of the Joint British Societies' guidelines, said NICE had previously made a ‘political' decision to recommend QRISK.

‘It is based on a British GP database and that is politically attractive, but like any GP database it is dirty. So for example 70% of values for HDL-cholesterol are imputed – that is made-up.

‘Social deprivation is another political thing to have in there. But I would like to see more data to show this really is an advance on Framingham.'

Dr Stewart Findlay, a GP in Bishop Auckland, County Durham, and treasurer of the Primary Care Cardiovascular Society, welcomed the decision, because he said GPs would have struggled to work with risks based on different calculations.

‘If we are going to make such a major change we have to be sure it is going to be one that is for the best and is sustainable,' he said.

NICE refused to comment on the decision.

CVD: NICE set to perform dramatic U-turn in lipid modification guidance CVD: NICE set to perform a dramatic U-turn in lipid modification guidance

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