New UK standards for familial hypercholesterolaemia
21 August 2013
New quality standards aim to improve diagnosis of familial hypercholesterolaemia (FH).
FH is a relatively common inherited condition that causes abnormally high levels of cholesterol to accumulate in the blood. If untreated it leads to premature atherosclerosis and coronary heart disease developing in young adults and even teenagers, with high risks of early death.
However, symptoms (besides elevated blood cholesterol) are rarely apparent and so the vast majority of the UK’s estimated 120,000 affected individuals go undetected, despite the importance of early diagnosis and prompt intervention (notably lifestyle advice and treatment with statins) in reducing heart disease risk.
The new standards aim to support existing guidance on the management of FH by improving diagnosis. They call for all adults with a baseline cholesterol level of more than 7.5mmol/l to be assessed for FH; for everyone with diagnosed FH to receive specialist assessment and care including DNA testing, lipid-modifying drug treatment (statins) and annual review; for all children at risk of FH to be offered diagnostic testing by the age of ten, and for all affected children to be assessed by a specialist for potential lipid-modifying drug treatment by the age of ten.The standards also specify that relatives of patients with known FH should also be offered diagnostic DNA testing ‘through a nationwide, systematic cascade process’, since they too have a high risk of also being affected.
These new standards are important in bringing FH to the fore as an area in urgent need of funding. The 2008 NICE guidance (which covers the care and treatment of adults and children with FH) specified the need for cascade screening to detect affected relatives. Whilst national cascade screening has been put in place in Scotland, Wales and Northern Ireland, no similar systems exist in England although (and perhaps because) it has by far the largest population and the greatest number of undetected FH cases. Failure to identify and treat them is a serious public health issue and places a significant burden on cardiovascular disease services via premature heart disease.
Hopefully the NICE standards will pave the way for appropriate funding and implementation of evidence-based actions to improve the diagnosis, cascade testing, management and treatment of FH in England. Ensuring that specialist clinicians are consistently able to access suitable testing and treatment options would be a valuable first step towards an equitable and effective national system.