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Gold, incentives and meh

No wish for dissent in CVD prevention

In reply to Dr Peter Brindle (‘Claims about QRISK do not serve debate’, pulsetoday., may I apologise for any offence my comments may have caused.

In reply to Dr Peter Brindle (‘Claims about QRISK do not serve debate', pulsetoday., may I apologise for any offence my comments may have caused.

I have no wish to cause unnecessary dissent in the field of cardiovascular disease prevention, which has for too long been riven by controversy, and controversy in medicine breeds inactivity.

That is the last thing we want when evidence for the benefit of statin and antihypertensive therapy is so strong.

It was for this reason I insisted anything I wrote as a counterpoint to Professor Julia Hippisley-Cox was seen by her before publication so she could respond to it in her article published at the same time.

I was not shown the editing or final version, so it is not correct to say the article was mine: rather it should be viewed as reporting.

Dr Brindle was himself a member of the NICE lipid management guideline development committee and so he would be better placed than me to know why QRISK was proposed as the method of CVD risk estimation in the draft guidance sent to stakeholders, yet in the final report a modified version of Framingham was recommended.

In the first report of QRISK based on the QRESEARCH database it was clearly stated that the median follow-up was six-and-a-half years (BMJ 2007;335:136).

In the next report, in which the THIN database was also studied, (and the QRISK equation modified) the median follow-up was around five years (Heart 2008;94:34).

In this latter report it is stated that HDL cholesterol was available in only 28.8% of male and 30.8% of female registrants in QRESEARCH and in 28.7% of men and 29.4% of women in THIN.

It would be remarkable if the total cholesterol to HDL cholesterol ratio was available more often than the HDL cholesterol.

The most important of my reported comments was that ‘we want to develop methods suited to the British population'. On this we agree.

Professor Hippisley-Cox and her co-workers clearly have an important part to play in that, but they have not yet modelled how effective QRISK would be in reducing CVD incidence in the British population compared with Framingham or with offering, say, statins simply on the basis of age.

Professor Paul Durrington

Professor of medicine at the University of Manchester

Editor's note

The QRISK2 evaluation published earlier this year (BMJ 2008; 336:a332) cites cholesterol-HDL ratios in the derivation cohort for 32.4% of men and 34.3% of women.

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