Implications of applying widely accepted cholesterol screening and management guidelines to a British adult population: cross sectional study of cardiovascular disease and risk factors

Abstract

Objective: To compare the implications of four widely used cholesterol screening and treatment guidelines by applying them to a population in the United Kingdom. Design: Guidelines were applied to population based data from a cross sectional study of cardiovascular disease and risk factors. Setting: Newcastle upon Tyne, United Kingdom. Subjects: General population sample (predominantly of European origin) of 322 men and 319 women aged 25-64 years. Main outcome measures: Proportions recommended for screening and treatment. Methods: Criteria from the British Hyperlipidaemia Association, the British Drugs and Therapeutics Bulletin (which used the Sheffield table), the European Atherosclerosis Society, and the American national cholesterol education programme were applied to the population. Results: Proportions recommended for treatment varied appreciably. Based on the British Drugs and Therapeutics Bulletin guidelines, treatment was recommended for 5.3% (95% confidence interval 2.9% to 7.7%) of men and 3.3% (1.5% to 5.3%) of women, while equivalent respective values were 4.6 (2.3 to 6.9) and 2.8 (1.0 to 4.6) for the British Hyperlipidaemia Association, 23% (18.4% to 27.6%) and 10.6% (7.3% to 14.0%) for the European Atherosclerosis Society, and 37.2% (31.9% to 42.5%) and 22.2% (17.6% to 26.8%) for the national cholesterol education programme. Only the British Hyperlipidaemia Association and Drugs and Therapeutics Bulletin guidelines recommend selective screening. Applying British Hyperlipidaemia Association guidelines, from 7.1% (4.3% to 9.9%) of men in level one to 56.7% (51.3% to 62.1%) of men in level three, and from 4.4% (2.1% to 6.7%) of women in level one to 54.4% (48.9% to 59.9%) of women in level three would have been recommended for cholesterol screening. Had the Drugs and Therapeutics Bulletin guidelines been applied, 22.2% (16.5% to 27.9%) of men and 12.2% (8.6% to 15.8%) of women would have been screened. Conclusions: Without evidence based guidelines, there are problems of variation. A consistent approach needs to be developed and agreed across the United Kingdom.

Estimating cardiovascular risk for primary prevention: outstanding questions for primary care

“…Like previous recommendations the new guidelines fail to adequately address the service consequences of their policies18 and leave primary care with an unresolved dilemma. Should lipid concentrations be measured in all adults, using the joint British tables, in 70% of the population, using the Sheffield tables, or in 15% of the population, using average lipid values rather than actual measured values?…”

Overprescribing of lipid lowering agents

“…However, a previous study showed that, although national guidelines varied, the NCEP guidelines would treat more patients than several other international guidelines. 29 Thus, this would not explain the association between international medical graduates and increasing overprescribing. In addition, the definition of oral agent was left to the respondent.…”

Seeking a second opinion: Do patients need a second opinion when practice guidelines exist?

“…They may be aware that results may be conflicting from one source to another [26,27] and may wonder whether their physician's decision is based on formal or informal consensus, or on evidence-based or explicit guidelines, all of which can yield different results. Some authors have shown that practice guidelines are seldom followed in everyday medical practice [28], suggesting that physicians are reluctant to use them.…”