By Lilian Anekwe
Exclusive: GPs face a ‘culture change’ in their management of cardiovascular disease with major new guidance to recommend use of a lifetime risk score rather than assessment of risk over 10 years using Framingham or QRISK.
Joint British Societies guidance will reject 10-year risk estimation – the basis of risk assessment for the past 35 years – in favour of a new score telling patients how likely they are to suffer a cardiovascular event at various points in their lives.
The long-awaited JBS3 guidance will shatter the consensus the organisation had forged with NICE over guidance on CVD, sparking a fierce debate among leading experts about whether the change is merited.
The move, which Pulse revealed last April was being considered by the JBS committee, could have profound implications for the QOF and vascular screening programme, which both use 10-year risk scoring.
The JBS3 guidance – due out in the spring – will launch a new lifetime risk score developed by the organisation, and recommend its use alongside ‘aggressive and broad control of modifiable risk factors’.
GPs will be encouraged to start tackling CVD at a much earlier stage and in far younger patients than now, with many qualifying for interventions who would currently fall below the 10-year risk threshold.
The revamp is prompted by concerns that use of 10-year risk scores means therapy is started too late for maximum benefit.
Professor John Deanfield, professor of cardiology at University College London and chair of the JBS3 guidance committee, said: ‘To get to a high cardiovascular risk under classic risk guidance patients need to be fairly old. The earlier years of life, when we are all quietly developing atherosclerosis, have been disregarded.
‘It’s a bit like investments – if you invest early you get a better gain down the line. Lifetime risk is becoming increasingly important. It’s a culture change in emphasis – it doesn’t mean necessarily earlier pills, but taking care of cardiovascular risk, mostly by lifestyle, from a much earlier stage.’
Professor Deanfield said JBS3 would provide GPs with a new risk score ‘allowing better communication with patients’ to help them meet ambitious targets set by Professor Roger Boyle, the Department of Health’s heart tsar who is also on the JBS3 guidance committee, to reduce CVD by more than 50% over the next 10 years.
He added: ‘We’ve got endpoints in the calculator like time to first CVD event, how long you live healthily before having an event and heart age, which we think are better communication strategies than classic 10-year risk.’
Dr Kathryn Griffith, a GP in York and president of the Primary Care Cardiovascular Society, said: ‘Age is such a big driver for risk that it does not make sense to wait until patients are older to treat them.’
Dr Mike Knapton, a GP in Cambridge and associate medical director at the British Heart Foundation, supported the move: ‘The JBS guidance is a rigorous piece of work and should feed through into NICE guidance and quality standards. To my mind the QOF does not reflect even JBS2, let alone JBS3.’
But Dr Rubin Minhas, clinical director of the BMJ Evidence Centre and a senior adviser to NICE, called switching to lifetime risk ‘a recipe for polypharmacy’, and said it was highly unlikely the institute would change its guidance: ‘By using lifetime risk, you are effectively committing everybody to medication. It’s inevitable. It offers very little value given we know everybody is going to die eventually.’
A NICE spokesperson said it would review the guidance, and conceded it was feasible cardiovascular QOF indicators could change to reflect ‘significant changes to the evidence base or changes in current practice’.
What the JBS3 guidance will recommend
• The use of a new lifetime risk calculator, including factors such as heart age and time until first cardiovascular event, to calculate patient’s absolute risk of an event over the rest of their lifetime.
• ‘Broad and aggressive’ intervention to modify risk factors from as early an age as possible.
• Improving compliance and follow-up to ‘make sure people get to target and stick to it’.
JBS to rip up rules on cardiovascular risk Right time for dramatic CVD changes?
• Emphasising the evidence that the same interventions benefit all CVD manifestations such as stroke, chronic kidney disease, diabetes and peripheral arterial disease.
• Importance of prevention over treatment.