The Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease (‘JBS3’), have now been published as a supplement to Heart.1 Although there was no primary care organisation represented on the JBS3 Board, there were nonetheless three cardiology experts whose careers include extensive knowledge and experience in primary care, who were involved in developing the JBS3 recommendations. The document will potentially be influential and there are two main changes in approach of which GPs need to be aware, as detailed below.
JBS3 is the largest version of this guidance to date (67 pages); the first version, published in 1998, referred only to coronary heart disease (CHD) and consisted of 29 pages, while JBS2 (published in 2005), was 52 pages.
Current assessment of cardiovascular disease (CVD) risk for primary prevention consists of measurement of the absolute 10-year risk of a vascular event and the provision of therapeutic intervention for blood pressure or cholesterol lowering above a specific threshold. This approach targets those at highest absolute risk, who stand to benefit most, but is heavily dependent on age and gender.
In order to address false reassurance, especially in young individuals and females with a high lifetime risk, it is recommended in JBS3 that a new JBS3 risk calculator is used to assess lifetime risk. As well as covering traditional risk factors, this calculator allows inputs for:
- family history
- the Townsend deprivation quintile2
- chronic kidney disease
- atrial fibrillation
- rheumatoid arthritis.
The graphics display a ‘heart age’ or vascular age, which is a comparison with a person of the same age, gender, and ethnicity with optimal risk factors, as well as the expected event-free CVD survival age. Although the JBS3 risk calculator is based on a large dataset and validation has been published, it is not based on randomly selected population samples and there are substantial data missing.1,3
The new calculator has received only limited testing in clinical practice. Research is needed on how to use the calculator in different populations to bring about behavioural change, especially in younger individuals who may be at lower short-term, but higher lifetime, risk.1 The feasibility of using the new calculator in a busy practice is not known and uptake will depend on its future incorporation into the quality and outcomes framework (QOF)4 and use by the NHS Health Checks.5
Cholesterol testing and statin
In JBS3, it is proposed that non-high-density lipoprotein cholesterol (non-HDL-c) levels are used as a better predictor of risk and treatment response. Non-HDL-c is a sum of cholesterol contained in all atherogenic apolipoprotein B (ApoB) lipoproteins (LDL-c and VLDL-c), whereas ApoB is a measure of the number of low-density lipoprotein (LDL) particles. The attraction of using non-HDL-c levels is that they are easily calculated and do not require a fasting sample. Practices will have difficulty adapting to this change. As the need to measure and reach cholesterol targets has been retired in the 2014/15 update to QOF4 (except for diabetic people), this change will be less likely to be implemented in GP practice.
The use of statin therapy, and its potential problems in those currently regarded as being at intermediate or lower risk of cardiovascular disease, is not without controversy. Cost is now less of a problem but JBS3 feels that adverse event rates with these drugs are uncommon and that their benefit/risk ratio is extremely high. The opposing view is that the side-effects of statins make them inappropriate for use in people at low risk of CVD.6
All aspects of CVD prevention are covered in the new document and recommendations are broadly in line with existing practice. Obstructive sleep apnoea is included because of its association with obesity and multiple cardiometabolic risk factors, both of which translate into increased CVD risk; however, it is not clear how obstructive sleep apnoea relates to CVD events. Also highlighted in JBS3 is:
- how treatment to lower blood pressure in people with a lacunar stroke did not lead to improved stroke prevention
- the timing for commencing statin therapy after an ischaemic stroke
- significant risks of haemorrhage from long-term dual antiplatelet therapy after a stroke.
In conclusion: although JBS3 is a consensus statement, its usefulness (as with all guidance) will depend on the degree to which its recommendations are adopted and how quickly practitioners adapt to measuring lifetime CVD risk. There is a huge educational challenge ahead for practice teams to play their part in implementing the recommended changes.
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- JBS3 Board. Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease (JBS3). Heart 2014; 100: ii1–ii67. Available at: heart.bmj.com/content/100/Suppl_2/ii1.full
- University of Bristol website. Townsend Centre for International Poverty Research. www.bristol.ac.uk/poverty/definingandmeasuringpoverty.html (accessed 2 May 2014).
- Perk J, Graham I, De Backer G. Prevention of cardiovascular disease: new guidelines, new tools, but challenges remain. Heart 2014: doi:10.1136/heartjnl-2014-305650 (published online first).
- British Medical Association. NHS England. NHS Employers. 2014/15 General Medical Services (GMS) contract quality and outcomes framework (QOF) guidance for GMS contract 2014/15. NHS Gateway reference 01264. Available at: www.nhsemployers.org/Aboutus/Publications/Documents/2014-15-QOF-guidance-stakeholders.pdf
- NHS Health Checks website. www.healthcheck.nhs.uk (accessed 1 May 2014).
- Kmietowicz K. Analysis fuels debate on statins for low risk people. BMJ 2014; 348: g2370. G