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29 March 2010
NICE has reissued its guideline on cardiovascular risk assessment and lipid modification (CG67) removing the recommendation to use a specific method for risk estimation (based on the Framingham equation). QRISK is an alternative method that can be considered. All other recommendations in the guideline are unchanged.
Action
The decision on which cardiovascular disease (CVD) risk assessment method to use in the NHS in England and Wales should be made locally. Both Framingham-based methods and QRISK can be considered. Where a Framingham-based method is chosen, previous NICE recommendations relating specifically to the use and modification of this equation (now in appendix D of the NICE guideline) are still appropriate. Education, training and support may be required locally to ensure consistent, optimal use of whichever risk estimation method is locally chosen.
NICE recommendations apply to the NHS in England and Wales. In Scotland, SIGN Guideline 97 (February 2007) specifically recommends the use of ASSIGN for the estimation of CVD risk.
Background
NICE provides some background to these changes in a press release on March 25th 2010. NICE was aware when the lipid modification guideline was published in May 2008 that the evidence on CVD risk estimation was developing rapidly. Following publication in 2009 of more evidence comparing QRISK (see NPC blog 378) with other risk estimation tools, the Institute’s Centre for Clinical Practice sought a view from members of the original guideline development group on whether the new evidence warranted an update of the guideline at this stage. There was no consensus among the members of the group that there was sufficient new evidence to allow for a clear decision in recommending one cardiovascular risk estimation method over another.
NICE’s Guidance Executive considered this feedback and came to the view that, although the evidence has moved on, an update was not appropriate as it did not seem that a clear conclusion would be reached favouring one method over another. In these circumstances the decision was taken to withdraw the guidance that the Framingham risk equation should be the equation of choice for assessment of CVD risk, but agreed that it should be one of the possible equations to use, and the decision could be left to the NHS locally to use the method best suited to their requirements. Specific recommendations relating to use and modification of the Framingham risk equation has been moved to appendix D of the NICE guideline and page 13 of the quick reference guide.
More information on the assessment of CVD risk can be found on the cardiovascular section of NPC.
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