By Lilian Anekwe
Exclusive: GPs could be encouraged to drive down cholesterol and blood pressure to much lower levels in patients with cardiovascular disease in Joint British Societies guidance due out this Spring, Pulse can reveal.
Major new guidance on the management of cardiovascular disease, currently being drafted by the JBS3 committee, will assess whether or not to set targets closer to levels achieved in clinical trials.
Professor John Deanfield, the chair of the committee, told Pulse that they were considering setting lower targets for cholesterol and blood pressure to hammer home the ‘tremendous gains' that have emerged from trials.
Professor Deanfield, professor of cardiology at University College London and consultant cardiologist at Great Ormond Street Hospital said: ‘There's been a drift down for individual risk factor targets based on evidence that lower is better for many risk factors.
'We're going to pick up on that and say what we considered to be good 10 years ago can be improved by current strategies.
‘The evidence in the literature has suggested with each passing study that you can achieve even more in the proper management of cardiovascular risk factors by targeting the risk factors to lower levels than we previously thought were acceptable.
‘Now obviously you're not going to get blood pressure down to zero, but getting people down to what is considered feasible and beneficial from clinical trials is a real opportunity for practitioners and for patients – not just saying "well that's all very well but it doesn't apply to me or my patients", but taking it seriously because of the tremendous gains that can be achieved. We're going to emphasise that and take on the new evidence.'
JBS2 already set ‘optimal' targets of 140/85mm Hg for blood pressure and less than 4.0 mmol/l for total and less than 2.0 mmol/l for LDL cholesterol, ‘or a 25% reduction in total cholesterol and a 30% reduction in LDL cholesterol, whichever gets the person to the lowest absolute value.'
In November a meta-analysis published in The Lancet concluded GPs should consider reducing LDL-cholesterol to below 2.0 mmol/l in high-risk patients, after finding there was 10% reduction in all-cause mortality, a 20% fall in coronary heart disease and an 11% drop in deaths from other cardiac causes for every 1.0 mmol/l reduction in LDL cholesterol – with benefits seen in patients starting with levels below 2.0 mmol/l. However, there was a three-fold increase in myopathy in patients on simvastatin 80mg.
But any recommendation of lower targets for either cholesterol or blood pressure will raise concerns over whether the reductions can be achieved safely.
Dr Terry McCormack, a GP in Whitby, Yorkshire and member of the NICE hypertension guideline development group said: ‘There's a difference between cholesterol and blood pressure. There's reasonable evidence that lower targets improve outcomes in patients cholesterol but it's a different story with blood pressure – the evidence for very low targets is not there.'
Dr Rubin Minhas, director of the BMJ clinical evidence centre and a GP member of the NICE guideline development group on lipid modification said: ‘Reducing cholesterol and blood targets too much will result in more polypharmacy and little patient benefit and possibly harm as with diabetes. Targets should be set following real life studies, rather than theory dictating practice.'GPs set for lower blood pressure and cholesterol targets