The National Institute for Health and Care Excellence (NICE) has updated its guidance on cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease (CVD).1 This article discusses the main recommendations and the implications of the update for general practice. New evidence on risk assessment tools and on statins and reduction in the cost of statins has resulted in significant changes to the level of risk at which treatment is recommended, and on the choice and dose of statins. The new guideline also incorporates guidance on lipid modification for people with type 1 and type 2 diabetes and with chronic kidney disease (CKD). See Box 1 for a summary of the main points of the revised lipid-modification guideline.
Box 1. Summary of the updated NICE lipid-modification guideline
Identifying high risk systematically
Prioritise those people for formal risk assessment based on an estimate of risk from information already known and recorded in the electronic medical record.
In those with an estimated 10-year risk of a CVD event >10% prioritise for full formal risk assessment. This is a change from the previous 20% risk threshold and will involve considerably more people.
Use the QRISK2 risk assessment tool for formal risk assessment for people age <84 years. This is a change from the choice between QRISK2 and Framingham-based assessment, previously recommended. QRISK2 is available on primary care computer systems.
Also use QRISK2 for those people with type 2 diabetes. This is a change from previous guidance which recommended UKPDS.
Do not use QRISK2 for people with type 1 diabetes. Because of high CVD risk, all adults with type 1 diabetes should be considered for statin therapy.
Do not use a risk assessment tool to assess CVD risk in people with an estimated glomerular filtration rate < 60 ml/min/1.73 m2 and/or albuminuria. It is known that these people already have high risk of CVD.
Do not use QRISK2 if there is high risk of developing CVD because of familial hypercholesterolaemia or other inherited disorders of lipid metabolism. These people need specialist assessment and guidance on treatment.
There are some groups of people who have other conditions where risk assessment will underestimate risk. Such as those with: HIV on treatment; serious mental health problems; taking antipsychotics, corticosteroids, or immunosuppressants; and systematic lupus erythematosus or other systemic inflammatory disorders.
People will need more time set aside to discuss their risk and treatment options. There will be a need to explore their current understanding and involve them in a shared management plan. In view of the numbers involved and the importance of informed patient choice, this may require increasing time and resources, plus additional training for healthcare workers.
Lifestyle advice
People should be offered the opportunity of further CVD assessment after attempting to modify their risk through lifestyle, if they wish. In some patients early treatment with statin may be preferred.
Dietary advice needs to be carefully provided, such as that available from NHS Choices.
Physical activity advice needs to be in line with national guidance.
Provide smoking cessation advice, support, and referral where appropriate.
Do not advise use of plant stanols or sterols to modify diet. This includes people with type 2 diabetes.
When to refer, when to start statins
Estimate risk from TC and HDL-cholesterol. The best estimate of risk and treatment effect is from non-HDL cholesterol. That is, TC minus HDL-cholesterol.
Before starting therapy for primary prevention take at least one further test for a full lipid profile, including TC, HDL-cholesterol, and triglycerides. The use of fasting samples is no longer necessary (unless initial triglyceride levels are >10 mmol/L).
Specialist assessment should be arranged if TC is >9.0 mmol/L or non-HDL cholesterol is >7.5 mmol/L.
Refer for urgent specialist review if triglycerides are >20 mmol/L. If triglycerides are >10 mmol/L after several measurements, also consider referral.
Offer people opportunity to have their risk of CVD assessed again after they have tried to change their lifestyle.
Offer atorvastatin 20 mg daily for primary prevention of CVD in those with >10% 10-year risk of CVD, including in those with type 2 diabetes and ‘significant’ CKD. This is a change from offering simvastatin 40 mg daily. It is based on the change in drug prices and an analysis of safety and cost effectiveness of higher intensity treatment.
Consider atorvastatin 20mg daily in people aged >85 years taking into account informed patient preference, comorbidities, polypharmacy, general frailty, and life expectancy. This is also a change and requires an assessment of potential for benefit in older people.
For secondary prevention in people with established CVD start treatment with atorvastatin 80 mg daily. Use a lower dose if there is a potential for drug interactions, high risk of adverse effects, or patient preference. This may require review of patients with history of angina, stroke, TIA, peripheral vascular disease, or myocardial infarction, at their annual medication check, and change of statin to atorvastatin 80 mg.
Monitoring treatment effect and dose increases
Measure TC and HDL-cholesterol after 3 months of treatment. Aim for a 40% reduction in non-HDL cholesterol. Consider increasing the dose up to 80 mg atorvastatin daily, if the 40% reduction is not achieved and the person is judged to be at higher risk because of comorbidities, risk score, or clinical judgement. This is a move away from the previous single dose strategy of simvastatin 40mg daily for people without diabetes or cardiovascular disease, and the previous cholesterol targets set for those with type 2 diabetes.
Creatine kinase should be measured in those who develop muscle symptoms such as pain, tenderness, or weakness. If >5 times the upper limit of normal the statin should be stopped. There is not normally a need for creatine kinase tests before starting a statin unless there are muscle symptoms.
Provide annual medication reviews for all those taking statins. For those stable on low- or moderate-intensity statins discuss the likely benefits and potential risks of changing to high intensity statin. Consider an annual non-fasting test for non-HDL cholesterol. This was not thought necessary previously for primary prevention but is now a consideration to help with adherence and to inform the discussion and related lifestyle advice.
Interventions not advised or offered
Do not offer fibrates routinely in any patient group. The previous NICE guidance was to offer fibrates in type 2 diabetes with high triglycerides, or statin intolerance.
Do not offer nicotinic acid (niacin) to prevent CVD.
Do not offer bile sequestrants (anion exchange resins) to prevent CVD.
Do not offer omega-3 fatty acid compounds to prevent CVD. These may have a role in specialist management, for example in hypertriglyceridaemia. This is a change from previous guidance which suggested a place for this treatment following myocardial infarction.
The place of ezetimibe is covered in separate guidance.
