BMJ  2003;327:E217 (4 October), doi:10.1136/bmjusa.03040003 (published 6 May 2003)

BMJ USA: Letter

RAPID RESPONSES FROM BMJ.COM

Drawbacks of primary prevention risk tables to assess cardiovascular risk in type 2 diabetes

Following is an edited excerpt from one of the Rapid Responses generated by this article, which can be read in their entirety at http://bmj.com/cgi/eletters/326/7383/251 — Editor

From BMJ USA 2003;April:202

Editor — The proposal implied by Hall et al would lead to a rather rigid prescribing protocol whereby all patients with scores above a threshold (eg, 15%) would receive additional therapy, and others would not. In addition, the overemphasis on risk scores might ignore other key risk factors not represented by the Framingham risk equation, such as ethnicity, family history, microalbuminuria, and triglyceride concentration. The low baseline prevalence of diabetes in the Framingham cohort leads to wide confidence intervals in the predicted risk (±5-10%). Thus, in a diabetic man with average risk factors, the upper 95% confidence interval crosses the 15% 10-year threshold from age 40 onwards. It is quite plausible that individuals with risk scores below a chosen cutoff have a higher true risk. The authors' proposal might lead to withholding treatment in a significant number of individuals.

It is conceivable that as new evidence emerges, a diagnosis of type 2 diabetes will be a prima facie reason to commence lipid-lowering therapy. Until such time, risk calculations based on Framingham data will continue to be incorporated into guidelines. However, we suggest that an overemphasis on this score to determine therapeutic decisions is unhelpful and might lead to the under-treatment of a significant number of patients.

Bristol Royal Infirmary, Bristol, UK jamie.smith{at}virgin.net

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