Posted on May 13, 2014 by Ruth Loftus
With Cardiovascular Disease (CVD) remaining the leading cause of human mortality across the entire world, any new initiative aimed at reducing avoidable deaths inevitably sparks interest and excitement. A recent proposal from the UK’s National Institute for Health and Clinical Excellence, to only prescribe drug treatment for people at mild risk of the disease, has certainly had this effect.
Death rates from CVD and related conditions in the west have been falling in recent decades as a consequence attributed to a particular lifestyle change: the dramatic reduction in the number of people who smoke. In addition, there have been improvements to the immediate treatment for people who have heart attacks or strokes. Despite these positive changes, CVD still remains the leading single cause of death, resulting in about 180,000 deaths in the United Kingdom each year.
One of the most significant factors contributing to the development of CVD is the level of cholesterol in the body. These days, cholesterol management is quite well understood but now, the National Institute for Heath and Care Excellence in the UK is suggesting that the active management of the condition be taken a step further.
Cholesterol or more specifically, low-density lipoprotein ( LDL) cholesterol, is produced in the liver. High levels of LDL are dangerous because they can lead to fatty deposits in the arteries which in turn cause thickening and narrowing of the arteries. This, in the worst case, results in a failure of the blood supply to the heart itself which is what we know to be a heart attack.
For some time, the drug type statins have proven to have a significant beneficial effect on this overall mechanism. Statins are able to control the production of LDL within the liver and have been prescribed to people with ‘bad cholesterol’ for approximately thirty years.
Up until recently, statins have been regarded as particularly effective for people who:
Already have some identified heart disease
May exhibit no evidence of heart disease but are seen as having a significant risk of heart disease in the future
Have a high cholesterol level as a result of inherited genetic factors or “familial hypercholesterolaemia”
The second group in the list is perhaps the most significant and will benefit the most from the new NICHE proposals. At present, statins are typically prescribed to people who are judged to be at a 20% risk of suffering a heart attack within a ten year time frame. A statistical technique known as QRisk2 is used to assess this and the measure takes account of age, weight, smoking and other aspects of medical history and lifestyle. A ten year 20% QRisk 2 score means in essence that, of 100 people with a similar rating, 20 would develop some form of heart disease in the next ten years.
The new suggestions from NIHCE are proposing that the benchmark for prescribing statins should be reduced to bring people with only a 10% risk of CVD into the frame for treatment.
The practice of prescribing medication for people who have no medical condition but who have a probability of developing one remains a little problematic - particularly now that the ‘probability’ threshold is progressively reduced.
The extension of the treatment to the lower risk group would increase the number of people undergoing such medication by a significant number (from about 7 million who are already taking the drug). As yet, NIHCE has not suggested a new figure, but it could be hundreds of thousands of people. Even though the cost of the drugs themselves has been decreasing in recent years, this new and increased number of drug patients would significantly increase the cost of this intervention from the present annual figure of about £450 million.
At present, it is assumed that the economic assessment of this intervention offsets the current cost of drugs against the savings of intensive and ongoing care for people who would otherwise have suffered heart attack or strokes. This arithmetic becomes more problematic if it then extends to account for people with a low probability of CVD
In addition, although statins have proved a powerful tool in the management of people at risk of CVD, they are not without their own risks and side effects. These include problems with muscles and also with vital organs such as the liver and kidneys. These problems have only occurred in a very small number of cases, but by expanding the scale of this treatment, more people would be put at risk.
The final issue rests upon the fact that personal choices about lifestyle, such as diet and exercise, will also have beneficial impact on cholesterol levels and incidence of CVD. Over a generation, with constant encouragement, impressive numbers of people have stopped smoking and as a result, this has had a dramatic impact on CVD. Indeed, NIHCE is proposing that advice about these lifestyle issues should also be a significant part of consultation before anyone is placed on this new treatment programme.