National service framework for coronary heart disease

Abstract

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.