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662m. Joint British Societies cardiovascular disease risk greater than twenty
percent up to thirty percent over next ten years
662n. Joint British Societies cardiovascular disease risk greater than thirty percent over next ten years
38DF. QRISK cardiovascular disease 10 year risk score
38DR. Framingham 1991 cardiovascular disease 10 year risk score
38DP. QRISK2 cardiovascular disease 10 year risk score
38B10 CVD (cardiovascular disease) risk assessment by third party
38G6. Joint British Societies cardiovascular disease risk score
38G8. Dundee CVS risk score
9hJ0. Excepted from cardiovascular disease quality indicators:
9hJ1. Excepted from cardiovascular disease quality indicators: informed dissent
9Oh9. Cardiovascular disease risk assessment declined
8IAK. Cardiovascular disease high risk review declined
8IEL. QRISK cardiovascular disease risk assessment declined
8IEV. QRISK2 cardiovascular disease risk assessment declined (v25)
9NSB. Unsuitable for QRISK2 cardiovascular disease risk assessment (v25)
U60CA [X]Statin causing adverse effect in therapeutic use
TJC24 Adverse reaction to simvastatin
TJC25 Adverse reaction to pravastatin
C10.. Diabetes mellitus
C109J Insulin treated Type 2 diabetes mellitus
C109K Hyperosmolar non-ketotic state in type 2 diabetes mellitus
C10C. Diabetes mellitus autosomal dominant
C10D. Diabetes mellitus autosomal dominant type 2
C10E% Type 1 diabetes mellitus
C10F% Type 2 diabetes mellitus (excluding C10F8. Reaven's syndrome)
C10G% Secondary pancreatic diabetes mellitus
C10H% Diabetes mellitus induced by non-steroid drugs
C10M% Lipoatrophic diabetes mellitus
C10N% Secondary diabetes mellitus
PKyP. Diab insipidus,diab mell,optic atrophy and deafness
C10P. Diabetes mellitus in remission (v28)
C10P0 Type I diabetes mellitus in remission (v28)
C10P1 Type II diabetes mellitus in remission (v28)
G734. Peripheral arterial disease
C3200 Familial hypercholesterolaemia
C3204 Fredrickson's hyperlipoproteinaemia, type IIa
C3205 Familial defective apolipoprotein B-100
C3203 Low-density-lipoprotein-type (LDL) hyperlipoproteinaemia
C3220 Familial combined hyperlipidaemia
1Z10. Chronic kidney disease stage 1
1Z11. Chronic kidney disease stage 2
1Z17. Chronic kidney disease stage 1 with proteinuria
1Z18. Chronic kidney disease stage 1 without proteinuria
1Z19. Chronic kidney disease stage 2 with proteinuria
1Z1A. Chronic kidney disease stage 2 without proteinuria
K051. Chronic kidney disease stage 1
K052. Chronic kidney disease stage 2
Cardiovascular disease (CVD) is the most common cause of death in the UK, and importantly for patients, the major cause of premature death (before 65 years). Moreover, of greater significance for the NHS, CVD is now the commonest cause of disability (through stroke and heart failure particularly) and hospital admission. This results in CVD being the major cost driver for health utilisation and remains the end point disease for many other chronic disorders, especially diabetes and renal disease.
Primary prevention (PP) works and evidence-based interventions can dramatically reduce risk – in North Karelia which had the highest CVD rates in Europe 25 years ago, CVD mortality has reduced by 50 per cent through rigid implementation of public health and individual patient interventions. Analysis of CHD trends in Ireland found that over a 15-year period, primary prevention achieved a two-fold larger reduction in CHD deaths than secondary prevention, with 68 per cent of the 2530 fewer deaths attributable to CHD (using the IMPACT CHD mortality model) having occurred in people without recognised CHD compared to 32 per cent in CHD patients.
For primary prevention of CVD, people at risk need to be identified before CVD has become established. To assess risk in those likely to be at high-risk (for example, people with hypertension) a validated assessment tool is needed that evaluates a range of modifiable and non-modifiable risk factors.
The NICE clinical guideline on lipid modification recommends statin
therapy for the primary prevention of CVD for adults who have an estimated 20
per cent or greater 10-year risk of developing CVD.
NICE clinical guideline CG67. Lipid modification
A number of risk assessment tools can be used to estimate cardiovascular risk for this QOF indicator. These include:
The three assessment tools listed above allow a structured risk assessment to be undertaken. However, each has a different age threshold; so to include the use of all three tools, the age range for this indicator has been set at aged 30 or over and under the age of 75. Contractors will be expected to use one of the three tools to assess their patients. If the tool normally available on the contractor’s clinical system is not age appropriate, one of the other tools may be used.
Framingham and JBS2 are based on the American Framingham equations. These equations are of limited use in the UK because they were developed in a historic US population. The equations overestimate risk by up to 50 per cent in most contemporary northern European populations, particularly for people living in more affluent areas and underestimate risk in higher risk populations, such as people who are the most socially deprived. Framingham makes no allowance for a family history of premature CHD and does not take account of ethnicity, but does have a full data set.
The newer risk score QRISK has the advantage of including other variables, such as measures of social deprivation, ethnicity and family history. QRISK uses data from UK general practice databases
Framingham and JBS2
The variables required for the estimation of risk using the Framingham risk assessment tool are age, sex, systolic blood pressure (mean of two previous systolic readings), total cholesterol, high density lipoprotein cholesterol, smoking status and presence of left ventricular hypertrophy. JBS2 utilises the Framingham variables with the exception of the presence of left ventricular hypertrophy.
Framingham is an assessment of actual, not estimated, risk. The values used should have been recorded no longer than six months before the date of the risk assessment and before any treatment for hypertension. Framingham is not suitable for patients with pre-existing CVD (CHD, angina, stroke, TIA or PAD), diabetes, CKD (if the patient has an eGFR below 60) or familial hypercholesterolemia, or in patients already taking lipid-lowering medication before a new diagnosis of hypertension.
The Framingham risk score may be used in patients aged 35 or over and under the age of 75. JBS2 may be used in people aged 40 or over.
The QRISK CVD risk calculator was developed by doctors and academics working in the NHS and is based on routinely collected data from general practitioners (GPs) across the country. The current version of QRISK is QRISK2(see www.qrisk.org). QRISK2 utilises the following variables to calculate CVD risk: self-assigned ethnicity, age, sex, smoking status, systolic blood pressure, total cholesterol, HDL cholesterol, BMI, family history of CHD in a first degree relative younger than 60, Townsend deprivation score, treated hypertension, type 2 diabetes, renal disease, AF and RA.
QRISK2 may be used in patients aged 30 or over and under the age of 85.
For people without clinical evidence of CVD, statin therapy is associated with a reduction of fatal and nonfatal MI and the composite outcome CHD death or nonfatal MI, fatal and nonfatal stroke and revascularisation. In trials predominantly comprising primary prevention but including a minority of people with established CVD, meta-analysis found that statin therapy was associated with a reduction in the risk of all-cause mortality, fatal and nonfatal MI and the composite outcomes of CHD death, nonfatal MI, fatal or nonfatal stroke and coronary revascularisation. For primary prevention lower intensity statins are safe and cost-effective. It is recommended that treatment for the primary prevention of CVD in patients with hypertension be initiated with simvastatin 40 mg. If there are potential drug interactions, or simvastatin 40 mg is contraindicated, a lower dose or alternative statin preparation may be chosen.
The NICE clinical guideline on lipid modification makes recommendations on how a 10-year CVD risk score of 20 per cent or greater should be managed. It also makes recommendations on communication between practitioners and patients about CVD risk assessment and treatment. These include the following.
• Setting aside adequate time during the consultation to provide information on risk assessment and to allow any questions to be answered.
• Documenting the discussion relating to the consultation on risk assessment and the patient’s decision.
• Offering information about the person’s absolute risk of CVD and about the absolute benefits and harms of an intervention over a 10-year period. This information:
1. presents individualised risk and benefit scenarios
2. presents the absolute risk of events numerically
3. uses appropriate diagrams and text.
See www.npci.org.uk for more information about explaining risk.
The guideline also recommends that if the patient's CVD risk is considered to be at a level that merits intervention but they decline the offer of treatment, they are advised that their CVD risk should be considered again in the future. The guideline also notes that CVD risk may be underestimated in people who are already taking anti-hypertensive or lipid modification therapy, or who have recently stopped smoking. It recommends that clinical judgement be used in such cases to decide on further treatment of risk factors in people who are below the 20 per cent CVD risk threshold.
For patients with hypertension, the guideline recommends that before they are offered lipid modification therapy for primary prevention, all other modifiable CVD risk factors are considered and their management optimised if possible. Baseline blood tests and clinical assessment are to be performed and co-morbidities and secondary causes of dyslipidaemia treated. Assessment includes:
• smoking status
• alcohol consumption
• BMI or other measures of obesity (see the NICE clinical guideline on Obesity223
• fasting total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides (if fasting levels are not already available) )
• fasting blood glucose
• renal function
• liver function (transaminases)
• TSH if dyslipidaemia is present.
The NICE guideline on lipid modification also recommends that the decision whether to initiate statin therapy is made after an informed discussion between the responsible clinician and the person about the risks and benefits of statin treatment, taking into account additional factors such as co-morbidities and life expectancy.
The guideline also states that a target for total or LDL cholesterol is not recommended for people who are treated with a statin for primary prevention of CVD and that once a person has been started on a statin for primary prevention, repeat lipid measurement is unnecessary. It is recommended that clinical judgement and patient preference should guide the review of drug therapy and whether to review the lipid profile.
See indicator wording for requirement criteria.
Patients with the following conditions are excluded from this indicator:
• CHD or angina
• stroke or TIA
• peripheral vascular disease
• familial hypercholesterolemia
• CKD with an eGFR below 30.
Verification - NHS England may request that the contractor randomly selects a number of case records of patients recorded as having had a risk assessment, to confirm that the key risk factors have been addressed and that biochemical and other clinical data used to inform the risk assessment are up-to-date. NHS England may also require contractors to demonstrate that age-appropriate risk assessment tools have been used.
Prepared By Jean Keenan