I don't entirely agree with David Plews on this..
For example David hasn't mentioned that age is the single most important
risk factor, and the studies have only documented risks for MI/CAD.
The funding of the drugs is a totally separate issue. Quality clinical
guidelines and costs of treatment must not be confused and this separation
is a major risk to the practise of good quality medicine. We have recently
had this problem in New Zealand. I was a GP member of our National Heart
Foundation Consensus Committee which was requested to give independent and
top quality advice. Not unexpectedly the drug funding body told us we were
in fantasyland. [They had to consider their annual bonuses of course.]
We (the profession) are not asking for GP's to follow the 4S evidence to
the "nth" degree, as it is clearly impracticable at the present time, but
we do most certainly need to weigh each case up on its merits. I believe
this patient has a risk far higher than 3% and I would treat her if she was
sprightly.
If the country didn't make provision for subsidising her medicine (and the
RCGP needs to be involved in making sure there are guidelines for GP's)
then she at least needs to have informed consent provided as to how much
(if any) of the costs she might like to consider herself - - if she values
the quality of her ageing years.
My father is 72 years and if he had a cholesterol of 9 mmol/L I would most
certainly be seeking treatment with the best EBM-medicine (EBM sometimes
has its uses when the evidence is convincing).
Jon Wilcox
The Other Side of the World (?? Fantasyland)
----------
> From: Dr David J Plews <[log in to unmask]>
> To: [log in to unmask]
> Subject: Re: Treating raised lipids
> Date: Saturday, 5 October 1996 08:47
>
> At 17:54 03/10/1996 +0100, Peter wrote:
> >Can I get some ideas from the "coalface" of general practice? I've a
> >72yr. old patient who had her first migrainous headache a few months
> >ago.I discussed her with our local neurologist who said,yes, it was a
> >bit uncommon but do a few bloods and wait and see if she gets more
> >before getting alarmed.Fairly wise as it turned out as she's had no more
> >but for some reason I included a lipid screen in her investigations and
> >her cholesterol came back as 9.6 and has not improved on dietary
> >treatment.She has no history or symptoms of IHD and her parents died of
> >old age. One sister had an MI at age 65+. I'm inclined to ignore it.
> >What would you do? I'd be most grateful for your opinions.
>
> Prof Ramsey in Sheffield has produced a really nice short paper on
treating
> raised cholesterol. Sorry can't remeber the reference, I can get it for
you
> if wish (seem to think it was in the Lancet).
>
> Basically it looks at risk factors. If your lady (and if I remeber this
> right) doesn't have hypertension, diabetes, LVH and isn't a smoker, then
as
> I recall her risk of a serious cardiac event is less than 3% per year.
For
> her risk to be greater than this her cholesterol would need to be over
10.
> The 3% level is the average risk of a serious cardiac event for post MI
and
> angina patients. So you don't need to treat.
>
> Prof Ramsey gave an evening lecturer recently in Rotherham. The
"terrifying"
> consequences of the 4S and WOSCOPS (?) studies prove that primary and
> secondary prevention of IHD by targeting risk factors and in particularly
> raised cholesterol are that the NHS drug bill could rise by over 25%
> treating at this 3% risk level. Buy shares in drug companies selling
> 'statins now. You'll make a killing (sic), especially as you then
wouldn't
> be able to prescribe their drugs:-)
>
> --------------------------
> Dr David J Plews
> email: [log in to unmask]
>


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