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Letters to the Editor
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Ischaemic events
NICE guidance fails to address key issues
From Dr S. Jarvis and others
After two years of review and consultation, the National Institute for
Clinical Excellence has just published guidance on the use of anti-platelet
agents for the prevention of occlusive vascular events in high risk patients.
As physicians with expertise in the management of these patients, we
had some concerns when the two appraisal consultation documents were
published. We highlighted these concerns to NICE and the institute has
taken some of our recommendations on board. However, two of our key issues
have not been addressed, and NICE appears to have missed the opportunity
to make a major contribution to government targets for reducing heart
disease in the population.
One problem is the inconsistency in NICE’s approach, such as the
decision to view each manifestation of occlusive vascular events separately,
even though NICE itself concedes that they have a common underlying cause.
The fundamental thrust of secondary prevention in ischaemic vascular
disease rests on the increased risk of patients who have suffered a cardiovascular
event. However, there is extensive evidence that patients suffering symptoms
in one vascular bed (eg, stroke or peripheral arterial disease) are at
greatly magnified risk of further events in another (eg, myocardial infarction),
as well as at the site of the index event. Surely, then, effective prevention
needs to address all manifestations of ischaemic vascular disease and
not tackle events in isolation.
We are also particularly concerned that NICE fails to achieve its stated
goal of offering practical guidance for doctors — where is the
advice on how to treat the many patients who have an event despite taking
the first choice of treatment, aspirin? These patients are at high risk
of having future vascular events, but NICE has steered away from the
issue. NICE has a difficult task trying to balance clinical improvements
with cost containment but, on this occasion, the messages lack clarity
and ignore the position of patients who fail to fit the criteria of an
artificially simplistic care pathway. The limitations of the new guidance
on occlusive vascular events need to be made clear to doctors, so that
they understand the need to continue to use their clinical judgement
in complex cases. Only by so doing can we ensure that, where NICE has
failed to address all issues, patients continue to be offered optimal
care.
Sarah Jarvis
GP, Richford, London
David Lindsay
Consultant Cardiologist, Gloucester Royal Hospital
Jonathan Morrell
GP, Hastings, East Sussex
Maureen Richmond
GP, St Hilary Brow Group Practice, Wallasy, Merseyside
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