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GPs face much tougher total cholesterol targets for secondary prevention of CHD under new draft guidelines.

The Scottish Intercollegiate Guidelines Network has provisionally recommended a target of 4mmol/l for all adults with clinical evidence of CHD ­ and NICE looks set to follow suit.

GPs warned it would be 'soul-destroying' to be faced with even more stringent targets after the hard work on the QOF, and questioned whether it would be cost-effective.

The release of the draft guidance this week came as NICE announced it was drawing up a clinical guideline on lipid modification in co-operation with SIGN.

A spokesman for NICE said: 'SIGN are a stakeholder in development of NICE guidelines. It's not like we will be working with total ignorance of what SIGN have been doing because they will bring that to the table.'

SIGN recommended the tougher target in CHD patients after reviewing the Prove-It and TNT trials, which found risk fell with further cholesterol reductions.

The SIGN draft also said it would be cost-effective to prescribe statins to all adults under 75 with a 20 per cent or greater 10-year risk of CHD ­ in accordance with the NICE draft appraisal on statins use.

Dr Dean Marshall, vice-chair of Scottish GPC, said: 'There is the workload for GPs and the increased prescribing costs. It's going to have to be adequately resourced.'

Dr Nev Bradley, chair of Wirral LMC and a GP in New Brighton, Wirral, said: 'I think we have done very well to get patients under 5mmol/l. Just continuing to add more rigorous targets is soul-destroying.

'Although the guidelines are in the best interest of patients, they will be difficult to achieve and demotivating. It's the last thing GPs want to hear.'

Dr John Ashcroft, CHD lead at Erewash PCT and a GP in Ilkeston, Derbyshire, said the guidance might not be cost-effective for patients not brought to target by 40mg simvastatin. 'The extra benefit of lowering the cholesterol that little bit more will come at a disproportionately high cost, unless the patient has a particularly high risk.'

The SIGN draft guidance will be discussed at a meeting next week and final guidance published next year.

By Nerys Hairon

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