Richard Watson’s response sounds very measured and calm, but I fear his stealth provides a Trojan Horse for drug company profiteering.
As a fellow GP I would agree he has every right to delay his first cardiovascular event by four years, by starting ramipril, amlodipine and atorvastatin, if it were his free choice and at his expense. But Richard calculated his own ASSIGN risk to be very low at 7.5% in 10 years. The chances are that he will not have a heart attack in his lifetime, and delaying the one after his 100th birthday and long dead is not a good use of NHS funds (ref 1). NICE calculates quite correctly that below 15% ten-year risk is not a cost-effective use of Statin. Cash could be better spent on cancer drugs, for example.
Richard has been beguiled by JBS3’s ‘lifetime risk’ calculator, which http://www.jbs3risk.com/ says ‘represents an opportunity for investment in future cardiovascular health’. It certainly represents a major opportunity for drug manufacturers to profit from NHS expenditure. The deceit of ‘Lifetime risk’ has been ably criticised elsewhere (ref 2), and should not traduce the NICE cost-effectiveness tools. Drug treatment of people with 10-year CVD risk below 15% yields very little benefit for individuals, with a large number of people exposed to side-effects, at a high net cost.
Richard is correct to say that ‘the arguments against the use of statins for primary prevention surely also apply to treatment of high blood pressure’. NICE has always argued that hypertension treatment should also be restricted to those at significant CVD risk. Mild hypertension in low-risk men (MRC trial last century, for example) required 800 man-years of treatment to prevent one stroke.
References
1. Pills in the sky
L Sam Lewis
BMJ 2008;336:174 (Published 24 Jan 2008)
2. Is estimating lifetime cardiovascular risk useful?
Rod Jackson, Andrew Kerr, Sue Wells
BMJ 2010;341:c7379 (Published 31 Dec 2010)
Rapid Response:
Richard Watson’s response sounds very measured and calm, but I fear his stealth provides a Trojan Horse for drug company profiteering.
As a fellow GP I would agree he has every right to delay his first cardiovascular event by four years, by starting ramipril, amlodipine and atorvastatin, if it were his free choice and at his expense. But Richard calculated his own ASSIGN risk to be very low at 7.5% in 10 years. The chances are that he will not have a heart attack in his lifetime, and delaying the one after his 100th birthday and long dead is not a good use of NHS funds (ref 1). NICE calculates quite correctly that below 15% ten-year risk is not a cost-effective use of Statin. Cash could be better spent on cancer drugs, for example.
Richard has been beguiled by JBS3’s ‘lifetime risk’ calculator, which http://www.jbs3risk.com/ says ‘represents an opportunity for investment in future cardiovascular health’. It certainly represents a major opportunity for drug manufacturers to profit from NHS expenditure. The deceit of ‘Lifetime risk’ has been ably criticised elsewhere (ref 2), and should not traduce the NICE cost-effectiveness tools. Drug treatment of people with 10-year CVD risk below 15% yields very little benefit for individuals, with a large number of people exposed to side-effects, at a high net cost.
Richard is correct to say that ‘the arguments against the use of statins for primary prevention surely also apply to treatment of high blood pressure’. NICE has always argued that hypertension treatment should also be restricted to those at significant CVD risk. Mild hypertension in low-risk men (MRC trial last century, for example) required 800 man-years of treatment to prevent one stroke.
References
1. Pills in the sky
L Sam Lewis
BMJ 2008;336:174 (Published 24 Jan 2008)
2. Is estimating lifetime cardiovascular risk useful?
Rod Jackson, Andrew Kerr, Sue Wells
BMJ 2010;341:c7379 (Published 31 Dec 2010)
Competing interests: No competing interests