Opinion  

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.