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'No evidence to back cholesterol targets'

By Lilian Anekwe

Cholesterol targets have gained their place at the core of GP care despite a complete lack of evidence for their effectiveness or safety, a new study concludes.

The controversial research challenges the whole basis of the QOF and the push for even tougher targets in Joint British Societies' guidelines.

GP cardiovascular experts described the paper as a 'bombshell' and predicted it would go 'all the way around the NHS'.

Researchers from the University of Michigan school of medicine and public health conducted a minute search for every scrap of evidence that might support LDL cholesterol targets.

But they found nothing to support chasing targets for LDL cholesterol below the level of 3.36mmol/l – which would include QOF targets.

There is no evidence 'the degree LDL cholesterol responds to a statin independently predicts the degree of cardiovascular risk reduction', the researchers wrote in the Annals of Internal Medicine.

Dr Rodney Hayward, professor of public health at the University of Michigan, said: 'Current clinical evidence does not demonstrate that titrating lipid therapy to achieve proposed low LDL cholesterol levels is beneficial or safe.'

The researchers stressed they did not doubt the benefits of statin therapy, particularly for high-risk patients, but were specifically questioning the value of targets.

Dr Malcolm Kendrick, a GP in Macclesfield who developed the educational website for the European Society of Cardiology, said: 'It's a bombshell. This review blows the QOF targets out of the water. There is a huge drive to lower LDL cholesterol, but the evidence doesn't stack up. This paper ought to provoke us to reassess how we practise.'

Dr Rubin Minhas, a board member of the Primary Care Cardiovascular Society, said: 'It's mega-big news. It's going all the way round the NHS and highlights the myth of targets.'

But Professor Bryan Williams, professor of medicine at the University of Leicester, said the study 'failed to acknowledge the practicalities of healthcare advice', insisting: 'Targets are a pragmatic way of implementing guidance.'

•No 'high-quality' evidence that titrating lipid therapy to a recommended target of <3.36mmol is="" more="" beneficial="" than="" empirically="" prescribing="" statins="" for="" high-risk="">

•Studies addressing benefits of achieving LDL cholesterol goals commonly have 'avoidable problems', and ignore the alternative proposed mechanisms of statin action

•Proposals for treatment goals should also consider risks, patient burden and societal costs of treatment

Source: Annals of Internal Medicine 2006;145:520-30

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