Three heart tools, one guideline and no answers

In a spectacular U-turn NICE has backtracked on its recommendations for cardiovascular risk assessment.

In February, NICE's draft guideline on lipid modification plumped for the new, UK-developed QRISK tool over the established, but much criticised, Framingham system. But this week it has reverted to the US scoring system - albeit with modifications - following calls for more work on and testing of QRISK.

NICE's decision is made more interesting by the moves to introduce ASSIGN, a third cardiovascular disease (CVD) risk tool, in Scotland - with pilots in Glasgow before a wider rollout.

However, NICE's decision does not settle the fundamental debate on what is the best way to assess CVD risk. There will in fact be different approaches in England and Wales to Scotland (with Northern Ireland left to choose, we assume).

Are the populations of Dumfries and Carlisle so radically different that they require different CVD scoring systems?

Yes, Scotland has significantly higher CHD prevalence than England (although Wales is closer) but that is surely due to having more people with risk factors, not a wildly different population.

Both QRISK and ASSIGN include deprivation as part of their scoring systems but will give differing risk results for the same patient, with Framingham offering a third option.

So the question remains: which one gives the most accurate prediction? Because that is the one that will save lives.

Much of the debate on this issue has been about factors other than the fundamental one of reducing CVD mortality.

One of the discussion points has been cost - more specifically which tool will reduce the statins bill. Following NICE's support for QRISK in February, some experts suggested it has favoured the tool because it would reduce the numbers meeting the threshold for statin treatment. Others argued that it would merely change who received statins.

Then there is the 'change is complicated' argument. Some doctors have rejected a change in risk tool without more study because, in effect, GPs are used to Framingham and changing to a new tool might be difficult.

Of course, these doctors are also concerned about the disruption caused by a move to the wrong tool, but that aspect of the problem can be obscured.

The key issue here is that there are three competing tools and what we need is the one that will save most lives. The whole of the UK needs to be investing on testing all the options now.

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