Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease

National Institute for Health and Clinical Excellence

Key priorities for implementation

Primary prevention of CVD

• For the primary prevention of CVD in primary care, a systematic strategy should be used to identify people aged 40–74 who are likely to be at high risk
• People should be prioritised on the basis of an estimate of their CVD risk before a full formal risk assessment. Their CVD risk should be estimated using CVD risk factors already recorded in primary care electronic medical records
• Risk equations should be used to assess CVD risk
  
• People should be offered information about their absolute risk of CVD and about the absolute benefits and harms of an intervention over a 10-year period. This information should be in a form that:
  • presents individualised risk and benefit scenarios
  • presents the absolute risk of events numerically
  • uses appropriate diagrams and text (See www.npci.org.uk)
• Before offering lipid modification therapy for primary prevention, all other modifiable CVD risk factors should be considered and their management optimised if possible. Baseline blood tests and clinical assessment should be performed, and comorbidities and secondary causes of dyslipidaemia should be treated. Assessment should include:
  • smoking status
  • alcohol consumption
  • blood pressure (see ‘Hypertension’, NICE clinical guideline 34)
  • body mass index or other measure of obesity (see ‘Obesity’, NICE clinical guideline 43)
  • fasting total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides (if fasting levels are not already available)
  • fasting blood glucose
  • renal function
  • liver function (transaminases)
  • thyroid-stimulating hormone (TSH) if dyslipidaemia is present
• Statin therapy is recommended as part of the management strategy for the primary prevention of CVD for adults who have a 20% or greater 10-year risk of developing CVD. This level of risk should be estimated using an appropriate risk calculator, or by clinical assessment for people for whom an appropriate risk calculator is not available or appropriate (for example, older people, people with diabetes or people in high-risk ethnic groups)
• Treatment for the primary prevention of CVD should be initiated with simvastatin 40 mg. If there are potential drug interactions, or simvastatin 40 mg is contraindicated, a lower dose or alternative preparation such as pravastatin may be chosen.

Secondary prevention of CVD

• For secondary prevention, lipid modification therapy should be offered and should not be delayed by management of modifiable risk factors. Blood tests and clinical assessment should be performed, and comorbidities and secondary causes of dyslipidaemia should be treated. Assessment should include:
  • smoking status
  • alcohol consumption
  • blood pressure (see ‘Hypertension’, NICE clinical guideline 34)
  • body mass index or other measure of obesity (see ‘Obesity’, NICE clinical guideline 43)
  • fasting total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides (if fasting levels are not already available)
  • fasting blood glucose
  • renal function
  • liver function (transaminases)
  • thyroid-stimulating hormone (TSH) if dyslipidaemia is present.
• Statin therapy is recommended for adults with clinical evidence of CVD
• People with acute coronary syndrome should be treated with a higher intensity statin. Any decision to offer a higher intensity statin should take into account the patient’s informed preference, comorbidities, multiple drug therapy, and the benefits and risks of treatment
• Treatment for the secondary prevention of CVD should be initiated with simvastatin 40 mg. If there are potential drug interactions, or simvastatin 40 mg is contraindicated, a lower dose or alternative preparation such as pravastatin may be chosen
• In people taking statins for secondary prevention, consider increasing to simvastatin 80 mg or a drug of similar efficacy and acquisition cost if a total cholesterol of less than 4 mmol/litre or an LDL cholesterol of less than 2 mmol/litre is not attained. Any decision to offer a higher intensity statin should take into account informed preference, comorbidities, multiple drug therapy, and the benefit and risks of treatment