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. 2000 Sep 9;321(7261):634.

National service framework for coronary heart disease

Ambiguities need to be clarified

Roger Lloyd-Mostyn 1
PMCID: PMC1118511  PMID: 11023318

Editor—One of the priorities in the national service framework for coronary heart disease summarised by Mayor1 was “improved use of effective medicines after heart attack—especially aspirin, β blockers, and statins—so that 80-90% of people discharged from hospital after a heart attack will be prescribed these drugs.” This is the recommendation in the executive summary, which taken at face value implies that all three drugs should be prescribed before a patient leaves hospital. In contrast, the recommendation in the main document is that aspirin and β blocker treatment should be started in hospital and statin treatment left for “continuing care.”

Statin treatment was not started at the time of infarction in any of the large secondary prevention studies. The shortest times from infarction to inclusion were six months in the Scandinavian simvastatin survival study (4S),2 and three months in the cholesterol and recurrent events (CARE) study3 and the long term intervention with pravastatin in ischaemic disease (LIPID) study.4 Thus the common practice of starting treatment before discharge is not strictly evidence based and statin treatment may be harmful immediately after myocardial infarction. Starting treatment before discharge, however, ensures that the drug is prescribed and simplifies audit.

A further recommendation in the main document is “give statins to lower serum cholesterol concentrations either to less than 5 mmol/l (low density lipoprotein cholesterol below 3 mmol/l) or by 30% (whichever is greater).” I find this ambiguous because a percentage change cannot be compared to a concentration, but I presume that the intention is to exclude from treatment those with a total cholesterol concentration under 5 mmol/l on admission. An audit of my own patients with myocardial infarction showed that statin treatment was not appropriate in 22% for this reason.

The main document states that patients with acute myocardial infarction should usually receive the recommended interventions unless contraindicated. Surely all patients without intolerance or contradindications should receive aspirin and β blockers. Similarly, all patients with a total cholesterol concentration greater than or equal to 5 mmol/l should be treated with a statin, but they may number less than 80% of the total. Whether the 80-90% standard above applies to all patients or to those without contraindications is not clear.

These ambiguities need to be clarified or the results of comparative audit will be meaningless. The criteria for audit should be as rigorous as those for clinical trials.

Footnotes

Competing interests: Dr Lloyd-Mostyn has been reimbursed for attending conferences and speaking at meetings by companies that manufacture lipid lowering drugs.

References

  • 1.Mayor S. Heart disease framework aims to cut deaths in England. BMJ. 2000;320:665. . (11 March.) [PubMed] [Google Scholar]
  • 2.Scandinavian Simvastatin Survival Group. Baseline serum cholesterol and treatment effect in the Scandinavian simvastatin survival study (4S) Lancet. 1995;345:1274–1275. [PubMed] [Google Scholar]
  • 3.Sacks FM, Pfeffer MA, Moye LA, Rouleau JL, Rutherford JD, Cole TG, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med. 1996;335:1001–1009. doi: 10.1056/NEJM199610033351401. [DOI] [PubMed] [Google Scholar]
  • 4.Long Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Group. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med. 1998;339:1349–1357. doi: 10.1056/NEJM199811053391902. [DOI] [PubMed] [Google Scholar]
BMJ. 2000 Sep 9;321(7261):634.

Target of lowering cholesterol by 30% needs to be justified

Paul Cracknell 1

Editor—The target cholesterol concentration of the national service framework for coronary heart disease seems to be problematic,1-1 which has important consequences for primary care. Most clinicians agree about the value of evidence based guidelines in preventing coronary heart disease and the need for clarity. But the recommendation to reduce cholesterol concentration by 30% is not based on evidence, and at worst seems to be arbitrary, thus weakening the document.

The issue of using cholesterol target concentrations or percentage reductions has been discussed,1-2 and the consensus among recent guidelines is to aim for a target cholesterol concentration of less than 5.0 mmol/l.1-3,1-4 The original guidance on the use of statins from the Standing Medical Advisory Committee in 1997 suggested a reduction in cholesterol concentration of 20-25% in line with the outcome trials, and the developers of the new Sheffield table1-5 suggest 25% (L E Ramsay, personal communication).

I am concerned that the national service framework's target of 30% will become a national audit standard that will be difficult to achieve, with adverse consequences for primary care. It would penalise good management, result in more visits and tests, and demoralise staff and patients. To achieve this target higher doses of statins might be used beyond the trial doses (40 mg), or most patients might be given atorvastatin (which does not have yet any trial evidence). Side effects may increase and the ratio of risk to benefit may shift. This has major implications as statins become more widely used in large populations. In the interests of fostering healthy debate, it would be helpful for the national service framework to justify the 30% figure.

Footnotes

Competing interests: None declared.

References

  • 1-1.Department of Health. National service framework for coronary heart disease. London: DoH; 2000. [Google Scholar]
  • 1-2.Rosengren A. Cholesterol: how low is low enough? BMJ. 1998;317:425–426. doi: 10.1136/bmj.317.7156.425. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-3.Wood D, Durrington P, Poulter N, McInnes G, Rees A, Wray R.on behalf of the British Cardiac Society, British Hyperlipidaemia Association, British Hypertension Society and endorsed by the British Diabetic association. Joint British recommendations on prevention of coronary heart disease in clinical practice Heart 199880(suppl 2)S1–29. [PMC free article] [PubMed] [Google Scholar]
  • 1-4.Scottish Intercollegiate Guidelines Network. Lipids and the primary prevention of coronary heart disease. Edinburgh: SIGN; 1999. . (Clinical guideline No 40.) [Google Scholar]
  • 1-5.Wallis EJ, Ramsay LE, Ul Haq U, Ghahramani P, Jackson PR, Rowland-Yeo K, et al. Coronary and cardiovascular risk estimation for primary prevention: validation of a new Sheffield table in the 1995 Scottish health survey population. BMJ. 2000;320:671–676. doi: 10.1136/bmj.320.7236.671. . (11 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2000 Sep 9;321(7261):634.

Many operators and facilities will not meet standards set out in framework

Kate Jolly 1,2,3, Andrew Rouse 1,2,3, Greg Y H Lip 1,2,3

Editor—Mayor's news item reported the publication of the national framework for coronary heart disease for England.2-1 Section 2 of the framework focuses on improving the quality of care offered to patients with coronary heart disease.2-2 It publishes standards that operators and facilities for interventional cardiological procedures are expected to achieve. Some of these standards address the annual number of cardiac catheterisations, coronary angioplasties, and coronary artery bypass operations that operators and facilities must achieve.

We used the hospital episode system database for the West Midlands for the most recent year available (1 April 1996 to 31 March 1997) for a study that we carried out. We calculated the proportion of facilities and consultant firms in the West Midlands providing services that complied with these new standards, and the proportion of patients treated by these facilities and consultant firms.

Data on the hospital episode system record the consultant firm, not the person doing the procedure, so we used the consultant firm as a proxy for the individual operator. The effect of this would be to overestimate the proportion of procedures done by “above threshold” operators. To reduce bias from coding errors we excluded consultants and trusts that undertook only one procedure during 1996-7 unless they had undertaken that procedure for three consecutive years.

The table shows the results. While 98% of patients had their coronary artery bypass grafting done in an above threshold facility by an above threshold consultant firm, the proportions for coronary angioplasty and cardiac catheterisation were only 73% and 71% respectively. We looked in more detail at cardiac catheterisations: of the 1780 patients treated in a below threshold facility, 1458 were operated on by an above threshold consultant firm. To comply with the national service framework's standards 10 facilities in the West Midlands would have to stop doing cardiac catheterisations (despite most patients being treated by cardiologists with an adequate caseload) or cases would have to be redistributed between hospitals.

Table.

Interventional cardiological procedures in 1996-7 with standards set out in national service framework for coronary heart disease. Values are numbers (percentages) unless stated otherwise

Cardiac catheterisation Coronary angioplasty Coronary artery bypass grafting
NSF standard for minimum No of procedures per facility 500 200 400
Institutions reaching threshold 5/15 (33) 3/8 (38) 3/3 (100)
NSF standard for minimum No of procedures per operator 100  75  50
Consultant firms reaching threshold 33/100 (33) 7/48 (15) 11/14 (79)
Total No of procedures during 12 month period 9037 1521 2308
Procedures in facility below threshold:
 By consultant firm below threshold 322 (3.5)  290 (19.1)   0
 By consultant firm above threshold 1458 (16.1)   0   0
Procedures in facility above threshold:
 By consultant firm below threshold 820 (9.1) 128 (8.4) 32 (1.4)
 By consultant firm above threshold 6437 (71.2) 1103 (72.5) 2276 (98.4) 
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NSF=national service framework. Denominators vary because of missing data. 

These findings show that unless cardiac catheterisation and coronary angioplasty practices have changed since 1996-7, many operators and facilities will not meet the standards set out in the national service framework. We are aware that over the past few years many more patients have undergone coronary stenting and angioplasty, and the proportion of patients treated by individual cardiologists is therefore likely to have improved. This, however, needs to be established.

Footnotes

Competing interests: None declared.

References

  • 2-1.Mayor S. Heart disease framework aims to cut deaths in England. BMJ. 2000;320:665. . (11 March.) [PubMed] [Google Scholar]
  • 2-2.Department of Health. National service framework for coronary heart disease. London: DoH; 2000. [Google Scholar]

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