MRCGP Exam Update - Lowering cholesterol levels

Current situation

- New targets for cholesterol levels have recently been introduced.

- There is a difference between expectation and actual achievement in statin prescribing - a study found that although GPs believed that 80 per cent of their patients were being successfully treated with statins, only 65 per cent of their patients were reaching target cholesterol levels (Br J Cardiol 2005; 12: 397).

- More surprisingly, nearly a quarter of GPs said that they would simply continue the unsuccessful treatment when faced with a patient who did not reach their target, rather than changing the dose or the medication.

What is the evidence?

- Lowering cholesterol levels with statins has been shown to reduce CHD event rates in both primary and secondary prevention trials.

- The Heart Protection Study demonstrated that simvastatin 40mg is beneficial in patients with diabetes, stroke, or peripheral vascular disease up to the age of 85 years (Lancet 2002; 360: 7-22). It showed that the relative risk reduction in major cardiovascular events was consistent irrespective of baseline LDL-cholesterol level, hence it appears that there is no lower threshold level.

- The Treating To New Targets study compared using atorvastatin 10-80mg in patients with CHD over five years (N Engl J Med 2005; 352: 1,425).

Lowering lipids to below 3mmol/l does increase benefits. Aggressively treated patients had a 2.2 per cent reduction in risk of a major cardiovascular event.

- Reducing LDL-cholesterol to very low levels carries no safety concerns (J Am Coll Cardiol 2005; 46: 1,411).

Implication for practice

- One study of 45- to 84-year-olds showed only 40 per cent of people taking lipid lowering treatment actually had cholesterol levels below target. The majority at low risk of cardiovascular disease (CVD) were treated, compared to only about half of those at high risk of CVD (Circulation 2006; 113: 647)

- Doctors are conservative in prescribing statins, though in trials, simvastatin has been shown to be most effective at 20mg daily (Br J Diabetes Vasc Dis 2004; (suppl 1): S5).

Further reading

- The new Joint British Societies guidelines state that all patients aged over 40 should have their cardiovascular risk assessed (Heart 2005; 91 (suppl V): 1).

Although the audit target remains at total cholesterol of 5mmol/l and an LDL of 3mmol/l, the target has now moved to 4mmol/l and 2mmol/l respectively.

- The NICE guidance on statins for the prevention of cardiovascular events was produced in January 2006.

It states that statin treatment is recommended for all adults with a 20 per cent or more 10-year risk of developing CVD.

USEFUL WEBSITES

www.nice.org.uk - NICE

www.bhsoc.org - BHS

- Dr Louise Newson is a GP in the West Midlands and author of 'Hot Topics for MRCGP and General Practitioners', Pas Test 2004

KEY POINTS

- Statin therapy reduces CHD events.

- More patients should be taking statins.

- Total cholesterol target is now 4mmol/l.

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