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Right time for dramatic CVD changes?



We’re only a couple of weeks into 2011, but already it looks like being a year as full of change for general practice as the one that has just ended.


The latest proposed overhaul is less instantly dramatic than those set out in the Government’s controversial white paper, but potentially just as significant for GPs’ day-to-day work.

The Joint British Societies want to end 10-year risk scoring, the basis for assessing cardiovascular risk since the birth of the Framingham score 35 years ago, and replace it with an entirely new system setting out the likelihood of suffering cardiac events across a patient’s lifetime.

Being assessed as at high risk would no longer be the preserve of the middle aged or elderly. Everyone whose lifestyle hints at a long-term future of cardiovascular debility would be presented with their own, personalised timebomb.

Professor John Deanfield, chair of the JBS3 guideline group, is evangelical about the need for GPs to intervene much earlier to moderate cardiovascular risk. He tells Pulse this week that there must be a ‘culture change’ to prevent the silent, unhindered progression of atherosclerosis.

But Professor Deanfield also insists, rather optimistically, that such a shift can be achieved without stratospherically increasing the number of younger patients on medication. He believes for most of those informed that their futures are shadowed by the possibility of cardiovascular illness, the answer will be early lifestyle advice, rather than premature popping of pills.

There is a flaw in his analysis. Professor Deanfield may well be right that lifetime risk will be better than current tools for opening a conversation with patients about their lifestyle.

But patients have an awkward habit of ignoring their doctors’ advice, even if the consequences of doing so could be lethal. The younger the patient, and more distant the risk, the harder persuasion can be.

Under lifetime risk scoring, GPs could be left with huge numbers of younger patients who had been handed a high-risk label, warned they were on the path to future cardiovascular disease, but with nothing to change their direction of travel.

It will be difficult for doctors to stand by, and many will inevitably reach for those cheap and handy statins. What may begin as a public health drive in its broadest sense could easily deliver the latest step-change on the road to mass medicalisation.

All this assumes JBS3 becomes embedded in GPs’ clinical practice. It may not be, given NICE appears reluctant to change its advice, and that 10-year risk scoring is so embedded in both the QOF and vascular screening.

But GPs are already facing upheaval, the NHS is under acute financial pressure and the evidence base for use of statins in primary prevention is under scrutiny – it does not seem the ideal time to launch an ambitious and potentially expensive assault on a core element of standard practice.

NICE and the JBS need to talk quickly, and decide whether they want lifetime risk to be simply a useful adjunct to current risk scoring, or if they really do want to turn the whole system of cardiovascular risk management upside down.

Editorial