Cholesterol and blood pressure-lowering treatment preventive treatments are less available to the most needy

People living in deprived areas or working in manual occupations are less likely to receive cholesterol and blood pressure-lowering treatment than more affluent people, according to a paper published in the November issue of the British Journal of General Practice.

This is because the method used to assess an individual’s risk of getting heart disease underestimates the true level of coronary heart disease risk associated with elevated risk factor levels in these groups.

Dr Peter Brindle, a researcher at the University of Bristol and a Bristol GP, said of the study: “Our results suggest that 4,196 people in the study, mainly from manual social classes, might have received preventative treatment, had the scoring method been properly calibrated for this high risk population. In fact, only 585 were eligible for treatment, leaving 3,611 people untreated.”

The study was led by Dr Brindle in collaboration with colleagues from Glasgow University, led by Professor Graham Watt.

The recommended way of preventing heart disease involves using the ‘Framingham’ risk score to identify high-risk patients. Patients above an agreed threshold are prescribed preventive treatments. However, the relevance of the Framingham score to the British population is uncertain, partly because the US data, on which it is based, are over 20 years old, and partly because the original study did not include areas with high levels of socio-economic deprivation, and the elevated risks associated with these groups.

The study involved 12,304 men and women from Renfrew and Paisley in Scotland (The MIDSPAN Study), who were free from cardiovascular disease. During the next 10 years, 696 died from cardiovascular disease, when only 406 deaths were predicted by the Framingham score.

While cardiovascular disease mortality was underestimated across the study population as a whole, for people in manual occupations the risk was underestimated by 48%, compared to 31% for people in non-manual work. The same effect was observed when comparing people living in affluent and deprived areas.

The conclusion from the study is that recommended risk scoring methods underestimate risk in socio-economically deprived individuals and that national screening could be contributing to health inequalities. The likely consequence is that preventive treatments are less available to the most needy.

Professor Watt commented: “Two very practical implications arise from this study. First, will nationally agreed clinical guidelines be adjusted to take account of the higher risks in people living in deprived areas? Second, if this is done, and the number of patients requiring preventive treatment is substantially increased, will general practices get the extra resources needed to treat, monitor and review these extra patients, ensuring they get the benefit of life-saving treatments?”

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