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Cardiovascular disease prevention

About

What is covered

This interactive flowchart covers cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease in adults.

Updates

Updates to this interactive flowchart

26 July 2017 Chronic kidney disease in adults (NICE quality standard 5) added.
26 September 2016 Meaning of high-intensity statin treatment clarified.
12 July 2016 Recommendation on saturated and monounsaturated fat clarified in diet.
21 June 2016 The following were added to intolerance or insufficient response to lipid-lowering therapy:
  • evolocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia (NICE technology appraisal guidance 394)
  • alirocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia (NICE technology appraisal guidance 393).
23 February 2016 Recommendations on ezetimibe for treating primary heterozygous-familial and non-familial hypercholesterolaemia in primary prevention, secondary prevention and intolerance or insufficient response to lipid-lowering therapy updated on publication of NICE technology appraisal guidance 385.
3 September 2015 Cardiovascular risk assessment and lipid modification (NICE quality standard 100) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on cardiovascular risk assessment and modifying blood lipids for preventing cardiovascular disease in adults

What is covered

This interactive flowchart covers cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease in adults.

Updates

Updates to this interactive flowchart

26 July 2017 Chronic kidney disease in adults (NICE quality standard 5) added.
26 September 2016 Meaning of high-intensity statin treatment clarified.
12 July 2016 Recommendation on saturated and monounsaturated fat clarified in diet.
21 June 2016 The following were added to intolerance or insufficient response to lipid-lowering therapy:
  • evolocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia (NICE technology appraisal guidance 394)
  • alirocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia (NICE technology appraisal guidance 393).
23 February 2016 Recommendations on ezetimibe for treating primary heterozygous-familial and non-familial hypercholesterolaemia in primary prevention, secondary prevention and intolerance or insufficient response to lipid-lowering therapy updated on publication of NICE technology appraisal guidance 385.
3 September 2015 Cardiovascular risk assessment and lipid modification (NICE quality standard 100) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Chronic kidney disease in adults (2011 updated 2017) NICE quality standard 5

Quality standards

Chronic kidney disease in adults

These quality statements are taken from the chronic kidney disease in adults quality standard. The quality standard defines clinical best practice in chronic kidney disease care for adults and should be read in full.

Quality statements

Full formal risk assessment using QRISK2

This quality statement is taken from the cardiovascular risk assessment and lipid modification quality standard. The quality standard defines clinical best practice in cardiovascular risk assessment and lipid modification and should be read in full.

Quality statement

Adults under 85 years with an estimated increased risk of cardiovascular disease (CVD) are offered a full formal risk assessment using the QRISK2 tool.

Rationale

A full formal risk assessment for adults who have been identified to have an estimated increased risk of CVD is the most accurate method of targeting prevention strategies to improve clinical outcomes. QRISK2 is the recommended formal risk assessment tool to assess CVD risk for the primary prevention of CVD in people up to and including the age of 84 years. QRISK2 is an online assessment tool for estimating the 10-year risk of having a cardiovascular event, in people who do not already have heart disease. A person’s 10-year risk of CVD can be used to inform treatment decisions, such as lifestyle advice or drug treatment.
Adults aged 85 years and over and those with existing CVD, type 1 diabetes, chronic kidney disease or familial hypercholesterolaemia should be considered to be at an increased risk of CVD events without using QRISK2. For these people, a full formal assessment with QRISK2 does not provide any additional information and could underestimate their risk of CVD, leading to inappropriate treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that the QRISK2 tool is used to formally risk assess adults under 85 years when an estimated increased risk of CVD is identified.
Data source: Local data collection.
Process
Proportion of adults under 85 years with an estimated increased risk of CVD who have a full formal risk assessment using the QRISK2 tool.
Numerator – the number in the denominator having a full formal risk assessment using the QRISK2 tool.
Denominator – the number of adults under 85 years with an estimated increased risk of CVD.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (primary care) ensure that systems are in place to offer adults under 85 years with an estimated increased risk of CVD a full formal risk assessment using the QRISK2 tool.
Healthcare professionals ensure that they offer a full formal risk assessment using the QRISK2 tool to adults under 85 years with an estimated increased risk of CVD.
Commissioners (NHS England area teams) ensure that they commission services that offer a full formal risk assessment using the QRISK2 tool to adults under 85 years with an estimated increased risk of CVD.

What the quality statement means for patients, service users and carers

Adults under 85 years who may be at risk of developing CVD are offered a risk assessment. The GP or nurse uses a computer program called QRISK2 to fully assess their risk of developing CVD over the next 10 years. This takes into account the person’s age, sex, smoking status, blood pressure and cholesterol levels, all of which can affect the risk of developing CVD. It will help identify adults who need lifestyle advice and possibly treatment to reduce their risk.

Source guidance

Definitions of terms used in this quality statement

Estimated increased risk of CVD
To estimate risk of CVD, use CVD risk factors that are already recorded in primary care electronic medical records using a systematic strategy. [Lipid modification (NICE guideline CG181) recommendations 1.1.1 and 1.1.2]
Adults aged 85 years and over, and those with pre-existing CVD or other clinical conditions that increase CVD risk (such as type 1 diabetes, familial hypercholesterolaemia or chronic kidney disease) are already considered at high risk and so should be excluded from estimations of increased risk and formal risk assessment. [Lipid modification (NICE guideline CG181) recommendations 1.1.9, 1.1.11, 1.1.15, 1.1.16, 1.1.21]
Full formal risk assessment
This assessment should use the online QRISK2 tool to assess the 10-year CVD risk for the primary prevention of CVD in people aged up to and including 84 years.

Equality and diversity considerations

The statement includes adults aged under 85 years because this is the population in which the QRISK2 tool is valid. Adults aged 85 years and older should be considered to be at high risk based on age alone, particularly those who smoke or have high blood pressure. Because QRISK2 calculates a person’s risk of CVD over the next 10 years, its risk scores may underestimate risk in younger people or women who have additional risk because of underlying medical conditions such as serious mental health problems or severe obesity (body mass index greater than 40 kg/m2). When using a QRISK2 risk score to inform treatment decisions in these populations, particularly if it is near the threshold for treatment, take into account other factors that may predispose the person to premature CVD that may not be included in calculated risk scores.

Excluding secondary causes

This quality statement is taken from the cardiovascular risk assessment and lipid modification quality standard. The quality standard defines clinical best practice in cardiovascular risk assessment and lipid modification and should be read in full.

Quality statement

Adults with a 10-year risk of cardiovascular disease (CVD) of 10% or more are assessed for secondary causes before any offer of statin therapy.

Rationale

Several conditions can increase a person’s risk of CVD, which may also cause dyslipidaemia (abnormal lipid levels). It is important that these are identified before starting statin therapy, which can cause side effects in adults with certain conditions. Common secondary causes of increased risk of CVD or dyslipidaemia include uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with a 10-year risk of CVD of 10% or more are assessed for secondary causes before any offer of statin therapy.
Data source: Local data collection.
Process
Proportion of adults with a 10-year risk of CVD of 10% or more who are assessed for secondary causes before any offer of statin therapy.
Numerator – the number in the denominator who are assessed for secondary causes before any offer of statin therapy.
Denominator – the number of adults with a 10-year risk of CVD of 10% or more.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (primary care) should ensure that adults with a 10-year risk of CVD of 10% or more are assessed for secondary causes before offering statin therapy. This assessment should be recorded and made available for any monitoring requests.
Healthcare professionals assess adults with a 10-year risk of CVD of 10% or more for secondary causes before offering statin therapy.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that GPs in their locality are aware of the need for adults with a 10-year risk of CVD of 10% or more to be assessed for secondary causes before offering statin therapy. Commissioners should include this requirement in any relevant local enhanced service specifications (for example, cardiovascular), according to local arrangements.

What the quality statement means for patients, service users and carers

Adults with a 1 in 10 or more chance of developing CVD in the next 10 years (a 10-year risk of 10% or more) are checked to see if there are any underlying causes before being offered treatment with a medicine called a statin. This will indicate whether there is another reason for their increased risk that might need a different treatment.

Source guidance

Definitions of terms used in this quality statement

Assessment for secondary causes
Secondary causes of increased CVD risk and dyslipidaemia include excess alcohol use, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome. An assessment for secondary causes of CVD risk or dyslipidaemia should include:
  • smoking status
  • alcohol consumption
  • blood pressure
  • body mass index
  • HbA1c
  • renal function and estimated glomerular filtration rate (eGFR)
  • transaminase level
  • thyroid-stimulating hormone.
[Lipid modification (NICE guideline CG181) recommendations 1.3.6, 1.3.13]

Equality and diversity considerations

The statement includes adults with a 10-year risk of CVD of 10% or more, as determined by their QRISK2 score if they are under 85 years. Adults aged 85 years and older should be considered to be at high risk based on age alone, particularly those who smoke or have high blood pressure. Because QRISK2 calculates a person’s CVD risk over the next 10 years, its risk scores may underestimate risk in younger people or women who have additional risk because of underlying medical conditions, such as serious mental health problems or severe obesity (body mass index greater than 40 kg/m2). When using a QRISK2 risk score to inform drug treatment decisions in these populations, particularly if it is near the threshold for treatment, take into account other factors that may predispose the person to premature CVD that may not be included in calculated risk scores.

Lifestyle advice for primary prevention

This quality statement is taken from the cardiovascular risk assessment and lipid modification quality standard. The quality standard defines clinical best practice in cardiovascular risk assessment and lipid modification and should be read in full.

Quality statement

Adults with a 10-year risk of cardiovascular disease (CVD) of 10% or more receive advice on lifestyle changes before any offer of statin therapy.

Rationale

Lifestyle changes such as stopping smoking, increasing physical activity, eating a healthy diet, managing weight and reducing alcohol consumption can reduce the risk of CVD. Lifestyle changes should be made, if possible, before statin treatment is offered, because these can reduce a person’s risk of CVD without the need for drug treatment. It is important that the benefits of lifestyle changes for primary prevention are discussed with adults at risk of CVD, to encourage uptake of lifestyle interventions before any offer of statin therapy.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with a 10-year risk of CVD of 10% or more receive advice on lifestyle changes before any offer of statin therapy.
Data source: Local data collection.
Process
Proportion of adults with a 10-year risk of CVD of 10% or more who receive advice on lifestyle changes before any offer of statin therapy.
Numerator – the number in the denominator who receive advice on lifestyle changes before any offer of statin therapy.
Denominator – the number of adults with a 10-year risk of 10% or more.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (primary care) ensure that processes are in place for adults with a 10-year risk of CVD of 10% or more to be given advice on lifestyle changes before any offer of statin therapy.
Healthcare professionals give advice on lifestyle changes to adults with a 10-year risk of CVD of 10% or more before they offer statin therapy.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that GPs are aware that adults with a 10-year risk of CVD of 10% or more should be given lifestyle advice before offering statin therapy. Commissioners may wish to consider incorporating this discussion into NHS Health Checks and local enhanced service specifications. Collaboration with local authorities (as the commissioner of NHS Health Checks) may be necessary to achieve this.

What the quality statement means for patients, service users and carers

Adults with a 1 in 10 or more chance of developing CVD in the next 10 years (a 10-year risk of 10% or more) are given advice on lifestyle changes, such as stopping smoking, losing weight, eating a healthy diet and exercising, before being offered statin therapy. These changes may help to reduce their chances of having a heart attack or stroke in the future.

Source guidance

  • Lipid modification (2014) NICE guideline CG181, recommendations 1.3.14, 1.3.15 and 1.1.27

Definitions of terms used in this quality statement

Lifestyle changes
Lifestyle changes include:
  • stopping smoking
  • eating a healthy diet
  • reaching and maintaining a healthy weight
  • increasing physical activity
  • reducing alcohol consumption.
[Lipid modification (NICE guideline CG181) recommendations 1.2.1–1.2.17]

Equality and diversity considerations

The statement includes adults with a 10-year risk of CVD of 10% or more, as determined by their QRISK2 score if they are under 85-years. Adults aged 85-years and older should be considered to be at high risk based on age alone, particularly those who smoke or have high blood pressure. Because QRISK2 calculates a person’s CVD risk over the next 10-years, its risk scores may underestimate risk in younger people or women who have additional risk because of underlying medical conditions, such as serious mental health problems or severe obesity (body mass index greater than 40-kg/m2). When using a QRISK2 risk score to inform drug treatment decisions, particularly if it is near the threshold for treatment, take into account other factors that may predispose the person to premature CVD that may not be included in calculated risk scores.
The lifestyle advice given should be sensitive to people's culture and faith, and tailored to their needs. An interpreter should be consulted if needed for people whose first language is not English.

Discussing risks and benefits of statins for primary prevention

This quality statement is taken from the cardiovascular risk assessment and lipid modification quality standard. The quality standard defines clinical best practice in cardiovascular risk assessment and lipid modification and should be read in full.

Quality statement

Adults with a 10-year risk of cardiovascular disease (CVD) of 10% or more for whom lifestyle changes are ineffective or inappropriate, discuss the risks and benefits of starting statin therapy with their healthcare professional.

Rationale

People who are better informed and involved in decisions about their care are more likely to adhere to their chosen treatment plan, which improves patient experience and clinical outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with a 10-year risk of CVD of 10% or more, for whom lifestyle changes are ineffective or inappropriate, discuss with their healthcare professional the risks and benefits of starting statin therapy.
Data source: Local data collection.
Process
Proportion of adults with a 10-year risk of CVD of 10% or more, for whom lifestyle changes are ineffective or inappropriate, with a recorded discussion on the risks and benefits of starting statin therapy.
Numerator – the number in the denominator who have a record of a discussion on the risks and benefits of starting statin therapy.
Denominator – the number of adults with a 10-year risk of CVD of 10% or more for whom lifestyle changes have been ineffective or are inappropriate.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (primary care) ensure that adults with a 10-year risk of CVD of 10% or more, for whom lifestyle changes are ineffective or inappropriate, have a documented discussion with their healthcare professional about the risks and benefits of starting statin therapy.
Healthcare professionals discuss the risks and benefits of starting statin therapy with adults who have a 10-year risk of CVD of 10% or more for whom lifestyle changes have been ineffective or are inappropriate, and record details of the discussion and the person’s decision.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that adults with a 10-year risk of CVD of 10% or more for whom lifestyle changes are ineffective or inappropriate have a documented discussion with their healthcare professional about the risks and benefits of starting statin therapy. Commissioners may do this by seeking evidence of practice, through clinical audits.

What the quality statement means for patients, service users and carers

Adults with a 1 in 10 or more chance of developing CVD in the next 10 years (a 10-year risk of 10% or more) for whom lifestyle changes have not helped or are unsuitable, discuss with their doctor the risks and benefits of starting statin therapy. This should include information about how statin therapy may help to reduce their chances of having a heart attack or stroke in the future.

Source guidance

Definitions of terms used in this quality statement

Ineffective lifestyle changes
Lifestyle changes such as stopping smoking, increasing physical activity and changing diet that have not resulted in a reduction in CVD risk when QRISK2 is repeated are considered to have been ineffective. Use clinical judgement to determine how long to wait before lifestyle changes are considered ineffective, because this depends on the type of lifestyle changes and the person’s wishes and needs. [Adapted from lipid modification (NICE guideline CG181) recommendation 1.3.16]
Discussion about the risks and benefits of statin therapy
The discussion should include information about a person’s risk of CVD and about the benefits and harms of statin therapy over a 10-year period. The discussion and the person’s decision should be documented. 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.
[Adapted from lipid modification (NICE guideline CG181) recommendations 1.1.25 and 1.1.26]
The NICE patient decision aid (2014) can be used to help make decisions about treatment with statins.

Equality and diversity considerations

The statement includes adults with a 10-year risk of CVD exceeding 10%, as determined by their QRISK2 score if they are aged under 85 years. Adults aged 85 years and older should be considered to be at high risk based on age alone, particularly those who smoke or have high blood pressure. Because QRISK2 calculates a person’s CVD risk over the next 10 years, its risk scores may underestimate risk in younger people or women who have additional risk because of underlying medical conditions, such as serious mental health problems or severe obesity (body mass index greater than 40 kg/m2). When using a QRISK2 risk score to inform drug treatment decisions, particularly if it is near to the threshold for treatment, take into account other factors that may predispose the person to premature CVD that may not be included in calculated risk scores.
The discussion about the risks and benefits of starting statin therapy should be sensitive to people's culture and faith, and tailored to their needs. An interpreter should be consulted if it is not appropriate to use an English-language-based patient decision aid, for example, for people whose first language is not English.

Statins for primary prevention

This quality statement is taken from the cardiovascular risk assessment and lipid modification quality standard. The quality standard defines clinical best practice in cardiovascular risk assessment and lipid modification and should be read in full.

Quality statement

Adults choosing statin therapy for the primary prevention of cardiovascular disease (CVD) are offered atorvastatin 20 mg.

Rationale

High-intensity statins are the most clinically effective treatment option for the primary prevention of CVD – that is, reducing the risk of first CVD events. After a discussion of the risks and benefits of starting statin therapy with a healthcare professional, a person may choose statin therapy as an appropriate treatment to reduce their risk of CVD. When a person decides to have statin therapy, a statin of high intensity and low cost should be offered. Atorvastatin 20 mg is recommended as the preferred initial high-intensity statin to use because it is clinically and cost effective for the primary prevention of CVD.

Quality measures

Structure
Evidence of local arrangements to ensure that adults who choose statin therapy for primary prevention are offered atorvastatin 20 mg.
Data source: Local data collection.
Process
Proportion of adults choosing statin therapy for primary prevention of CVD who are prescribed atorvastatin 20 mg.
Numerator – the number in the denominator prescribed atorvastatin 20 mg.
Denominator – the number of adults choosing statin therapy for primary prevention of CVD.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (primary care) ensure that adults choosing statin therapy for primary prevention of CVD are offered atorvastatin 20 mg.
Healthcare professionals offer atorvastatin 20 mg to adults choosing statin therapy for primary prevention of CVD.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that adults who choose statin therapy for primary prevention of CVD are offered atorvastatin 20 mg. Commissioners may do this by seeking evidence of practice through clinical audits.

What the quality statement means for patients, service users and carers

Adults at risk of CVD who choose to have a statin to reduce their chances of CVD are offered one called atorvastatin. This may help to reduce their chances of having a heart attack or stroke in the future.

Source guidance

Statins for secondary prevention

This quality statement is taken from the cardiovascular risk assessment and lipid modification quality standard. The quality standard defines clinical best practice in cardiovascular risk assessment and lipid modification and should be read in full.

Quality statement

Adults with newly diagnosed cardiovascular disease (CVD) are offered atorvastatin 80 mg.

Rationale

High intensity statins are the most clinically effective option for the secondary prevention of CVD – that is, reducing the risk of future CVD events in people who have already had a CVD event, such as a heart attack or stroke. Evidence shows that atorvastatin 80 mg is the most cost effective high intensity statin for the secondary prevention of CVD, which can improve clinical outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with newly diagnosed CVD are offered atorvastatin 80 mg.
Data source: Local data collection.

Process

Proportion of adults with newly diagnosed CVD who are prescribed atorvastatin 80 mg.
Numerator – the number in the denominator prescribed atorvastatin 80 mg.
Denominator – the number of adults with newly diagnosed CVD.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (primary care and secondary care) ensure that adults with newly diagnosed CVD are offered atorvastatin 80 mg.
Healthcare professionals offer atorvastatin 80 mg to adults with newly diagnosed CVD.
Commissioners (NHS England area teams and clinical commissioning groups) ensure that adults with newly diagnosed CVD are offered atorvastatin 80 mg. Commissioners may do this by seeking evidence of practice through clinical audits.

What the quality statement means for patients, service users and carers

Adults who have been newly diagnosed with CVD are offered a statin called atorvastatin to help reduce their chances of further problems, such as a heart attack or stroke.

Source guidance

Definitions of terms used in this quality statement

Atorvastatin 80 mg
At the time of publication (September 2015) atorvastatin did not have a UK marketing authorisation for secondary prevention of CVD. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

Side effects of high-intensity statins

This quality statement is taken from the cardiovascular risk assessment and lipid modification quality standard. The quality standard defines clinical best practice in cardiovascular risk assessment and lipid modification and should be read in full.

Quality statement

Adults on a high-intensity statin who have side effects are offered a lower dose or an alternative statin.

Rationale

The use of high-intensity statins can cause side effects, but to improve clinical outcomes it is important that alternative strategies are tried rather than stopping treatment. Any statin at any dose reduces the risk of cardiovascular disease (CVD).

Quality measures

Structure
Evidence of local arrangements to ensure that adults on a high-intensity statin are monitored for side effects and offered a lower dose or an alternative statin if necessary.
Data source: Local data collection.
Process
Proportion of adults reporting side effects from a high-intensity statin who are given a lower dose or alternative statin.
Numerator – the number in the denominator at which a lower dose or alternative statin is prescribed.
Denominator – the number of presentations of adults reporting side effects from a high-intensity statin.
Data source: Local data collection.
Outcome
Adherence to statin therapy.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (primary care and secondary care) should ensure that adults on a high-intensity statin who have side effects are offered a lower dose or an alternative statin. Service providers should see recommendation 1.3.42 in NICE’s guideline on lipid modification for further information.
Healthcare professionals offer a lower dose or an alternative statin to adults who have side effects from a high-intensity statin.
Commissioners (NHS England area teams and clinical commissioning groups) should ensure that providers are aware that adults on a high-intensity statin who have side effects should be offered a lower dose or an alternative statin.

What the quality statement means for patients, service users and carers

Adults taking a statin who have side effects are offered a lower dose or a different type of statin.

Source guidance

Definitions of terms used in this quality statement

High-intensity statin
The intensity of a statin is defined based on the percentage reduction in low-density lipoprotein (LDL) cholesterol it can produce. A high-intensity statin can produce a reduction above 40%. High-intensity statins include:
  • atorvastatin 20 mg to 80 mg
  • rosuvastatin 10 mg to 40 mg
  • simvastatin 80 mg. [Lipid modification (NICE guideline CG181)]

3-month statin review

This quality statement is taken from the cardiovascular risk assessment and lipid modification quality standard. The quality standard defines clinical best practice in cardiovascular risk assessment and lipid modification and should be read in full.

Quality statement

Adults on a high-intensity statin have a repeat measurement of lipids and liver transaminases after 3 months of treatment.

Rationale

Repeating lipid profiles and measuring liver transaminases is important for patient safety and to ensure the effectiveness of statin therapy. A repeat lipid profile can be used to determine whether the expected 40% reduction in non-high-density lipoprotein (non-HDL) cholesterol has been achieved. Repeat measurement of liver transaminase is important to detect any increased levels of these enzymes, which may indicate problems with liver function.

Quality measures

Structure
Evidence of local arrangements to ensure that adults on a high-intensity statin have a repeat measurement of lipids and liver transaminases after 3 months of treatment.
Data source: Local data collection.
Process
Proportion of adults on high-intensity statins who have had a repeat measurement of lipids and liver transaminases after 3 months of treatment.
Numerator – the number in the denominator who have had a repeat measurement of lipids and liver transaminases after 3 months of treatment.
Denominator – the number of adults prescribed high-intensity statins for at least 3 months.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (primary care) ensure that adults on a high-intensity statin have a repeat measurement of lipids and liver transaminases after 3 months of treatment. Evidence should be made available on request to commissioners.
Healthcare professionals take a repeat measurement of lipids and liver transaminases after 3 months of treatment for adults on high-intensity statins.
Commissioners (NHS England area teams and clinical commissioning groups) should monitor whether adults on a high-intensity statin have a repeat measurement of lipids and liver transaminases after 3 months of treatment. Commissioners may wish to stipulate this in any local enhanced service specifications.

What the quality statement means for patients, service users and carers

Adults taking a statin have a review 3 months after their treatment starts to see if the statin is reducing their cholesterol levels and to check it is not affecting their liver.

Source guidance

Definitions of terms used in this quality statement

High-intensity statin
The intensity of a statin is defined based on the percentage reduction in low-density lipoprotein (LDL) cholesterol it can produce. A high-intensity statin can produce a reduction above 40%. High-intensity statins include:
  • atorvastatin 20 mg to 80 mg
  • rosuvastatin 10 mg to 40 mg
  • simvastatin 80 mg. (Lipid modification [NICE guideline CG181])

Identifying people with an estimated increased risk: placeholder statement

This placeholder quality statement is taken from the cardiovascular risk assessment and lipid modification quality standard. The quality standard defines clinical best practice in cardiovascular risk assessment and lipid modification and should be read in full.

What is a placeholder statement?

A placeholder statement is an area of care that has been prioritised by the Quality Standards Advisory Committee but for which no source guidance is currently available. A placeholder statement indicates the need for evidence based guidance to be developed in this area.

Rationale

Cardiovascular disease (CVD) is the most common cause of death in the UK, and is a major cause of illness, disability and poor quality of life. To improve primary prevention, people at increased risk of CVD need to be identified and their risk factors managed in the most effective way. It is estimated that half of men over 50 and one fifth of women over 65 have a CVD risk of 20% or more. Current guidance recommends using a systematic strategy in primary care using electronic records to identify people with an estimated increased risk of CVD. However, clarification of the strategies to prioritise people for assessment was not included in guideline recommendations. Further guidance is needed on methods to use across the healthcare pathway to identify people with an estimated increased risk of CVD, how frequently this identification should be done and which healthcare professionals should carry it out.

Identification and monitoring

This quality statement is taken from the chronic kidney disease in adults quality standard. The quality standard defines clinical best practice in chronic kidney disease (CKD) care for adults and should be read in full.

Quality statement

Adults with, or at risk of, chronic kidney disease (CKD) have eGFRcreatinine and albumin:creatinine ratio (ACR) testing at the frequency agreed with their healthcare professional.

Rationale

Routine monitoring of key markers of kidney function for adults with, or at risk of, CKD will enable earlier diagnosis and early action to reduce the risks of CKD progression, such as cardiovascular disease, end-stage kidney disease and mortality.

Quality measures

Structure
Evidence of local systems that invite adults with, or at risk of, CKD to have eGFRcreatinine and ACR testing.
Data source: Local data collection, for example, through local protocols on appointment reminders.
Process
a) Proportion of adults with CKD who had eGFRcreatinine testing in the past year.
Numerator – the number in the denominator who had eGFRcreatinine testing in the past year.
Denominator – the number of adults with CKD.
Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with coded CKD stages 3 to 5 with a repeat blood test of their kidney function in the past year.
b) Proportion of adults with CKD who had ACR testing at the frequency agreed with their healthcare professional.
Numerator – the number in the denominator who had ACR testing at the frequency agreed with their healthcare professional.
Denominator – the number of adults with CKD.
Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with coded CKD stages 3 to 5 who had an ACR urinary test result in the previous year.
c) Proportion of adults at risk of CKD who had eGFRcreatinine testing at the frequency agreed with their healthcare professional.
Numerator – the number in the denominator who had eGFRcreatinine testing at the frequency agreed with their healthcare professional.
Denominator – the number of adults at risk of CKD.
Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with diabetes tested using serum creatinine in the past year, and people at risk of CKD without diabetes tested in the past 5 years.
d) Proportion of adults at risk of CKD who had ACR testing at the frequency agreed with their healthcare professional.
Numerator – the number in the denominator who had ACR testing at the agreed frequency.
Denominator – the number of adults at risk of CKD.
Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with diabetes tested using ACR in the past year, and people at risk of CKD without diabetes tested in the past 5 years.
Outcomes
a) Prevalence of undiagnosed CKD.
Data source: NHS Digital’s Quality and Outcomes Framework 2015–16 reports the prevalence of patients aged 18 or over with CKD with classification of categories G3a to G5 registered at GP practices. Comparing recorded prevalence with expected prevalence estimated using a tool, such as Public Health England’s CKD prevalence model, can give an indication of local prevalence of undiagnosed CKD.
b) Stage of CKD at diagnosis.
Data source: Local data collection, for example, audit of health records.

What the quality statement means for different audience

Service providers (general practices and secondary care services, such as renal, cardiology, diabetes and rheumatology clinics) ensure that systems are in place to identify adults with, or at risk of, CKD, for example through computerised or manual searching of medical records, and offer an appointment to discuss with them how frequently they should have eGFRcreatinine and ACR testing. They also have systems in place to offer appointments for testing at the agreed frequency.
Healthcare professionals (GPs, nephrologists, cardiologists, diabetologists, rheumatologists, nurses and pharmacists) discuss and agree the frequency of eGFRcreatinine and ACR testing with adults who have, or at risk of, CKD and offer testing at the agreed frequency. They can then agree any appropriate treatment based on the results of testing.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults with, or at risk of, CKD have eGFRcreatinine and ACR testing at the frequency agreed with their healthcare professional. They might do this by checking that services have systems in place to identify adults with, or at risk of, CKD and offer appointments to discuss and agree the frequency of eGFRcreatinine and ACR testing.
Adults who have, or may be at risk of, CKD discuss and agree with their healthcare professional how often they should have tests to check how well their kidneys are working. They are offered blood and urine tests at the agreed frequency to find out if their CKD is worsening (progressing), or if they have kidney problems. The blood test is at least once a year for adults with CKD. People with CKD are offered information and education relevant to the cause of kidney disease, how advanced it is, any complications they may have and the chances of it getting worse, to help fully understand and make informed choices about treatment. They are also be able to get psychological support if needed – for example, support groups, counselling or support from a specialist nurse.

Source guidance

Chronic kidney disease in adults: assessment and management (2014) NICE guideline CG182, recommendations 1.1.27, 1.1.28 (key priority for implementation), 1.3.1 and 1.3.2 (key priority for implementation).

Definitions of terms used in this quality statement

Adults with CKD
CKD is defined as abnormalities of kidney function or structure present for more than 3 months, with implications for health. This includes:
  • people with markers of kidney damage, including albuminuria (ACR more than 3 mg/mmol), urine sediment abnormalities, electrolyte and other abnormalities due to tubular disorders, abnormalities detected by histology, structural abnormalities detected by imaging or a history of kidney transplantation
  • people with a glomerular filtration rate (GFR) of less than 60 ml/min/1.73 m2 on at least 2 occasions separated by a period of at least 90 days (with or without markers of kidney damage).
(NICE’s guideline on chronic kidney disease in adults)
Adults at risk of CKD
Adults with any of the following risk factors:
  • diabetes
  • hypertension
  • acute kidney injury
  • cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vascular disease or cerebral vascular disease)
  • structural renal tract disease, recurrent renal calculi or prostatic hypertrophy
  • multisystem diseases with potential kidney involvement – for example, systemic lupus erythematosus
  • family history of end-stage kidney disease (GFR category G5) or hereditary kidney disease – for example, autosomal dominant polycystic kidney disease
  • opportunistic detection of haematuria
  • prescribed drugs that have an impact on kidney function, such as calcineurin inhibitors (for example, cyclosporin or tacrolimus), lithium and non-steroidal anti-inflammatory drugs (NSAIDs).
(NICE’s guideline on chronic kidney disease in adults, recommendations 1.1.27 and 1.1.28 and expert opinion)
eGFRcreatinine testing
A blood test that estimates glomerular filtration rate (GFR) by measuring serum creatinine. It is used as an estimate of kidney function to identify kidney disease and monitor CKD progression. Clinical laboratories should use the Chronic Kidney Disease Epidemiology Collaboration (CKD‑EPI) creatinine equation to estimate GFRcreatinine, using creatinine assays with calibration traceable to standardised reference material.
(Adapted from NICE’s guideline on chronic kidney disease in adults, recommendation 1.1.2)
Albumin:creatinine ratio (ACR) testing
A test used to detect and identify protein in the urine, which is a sign of kidney disease, and can be used to assess progression of CKD.
(Adapted from NICE’s guideline on chronic kidney disease in adults, recommendation 1.1.18 and full guideline)
At the frequency agreed with their healthcare professional
The frequency of monitoring should be discussed and agreed by the person and their healthcare professional. Table 2 in NICE’s guideline on chronic kidney disease in adults should be used to guide the frequency of GFR monitoring. Adults with CKD should be seen at least annually and adults at risk of CKD can be seen annually or less often for monitoring of eGFR. ACR does not need to be measured every time eGFR is measured, except when evaluating response to a treatment targeted at reducing proteinuria. Frequency of monitoring is determined by the stability of kidney function and the ACR level, and tailored to the individual according to:
  • the underlying cause of CKD
  • past patterns of eGFR and ACR (but be aware that CKD progression is often non-linear)
  • comorbidities, especially heart failure
  • changes to their treatment (such as renin–angiotensin–aldosterone system [RAAS] antagonists, NSAIDs and diuretics)
  • intercurrent illness
  • whether they have chosen conservative management of CKD.
(Adapted from NICE’s guideline on chronic kidney disease in adults, recommendations 1.3.1 and 1.3.2 and full guideline)

Blood pressure control

This quality statement is taken from the chronic kidney disease in adults quality standard. The quality standard defines clinical best practice in chronic kidney disease (CKD) care for adults and should be read in full.

Quality statement

Adults with chronic kidney disease (CKD) have their blood pressure maintained within the recommended range.

Rationale

People with CKD are at a higher risk of high blood pressure. Maintaining blood pressure within a target range reduces the risk of cardiovascular disease, CKD progression and mortality.

Quality measures

Structure
a) Evidence of local systems to identify and invite adults with CKD to have a blood pressure reading.
Data source: Local data collection, for example, through local protocols on appointment reminders.
b) Evidence of the availability of equipment to take a blood pressure reading from adults with CKD.
Data source: Local data collection, for example, service specifications.
Process
a) Proportion of adults with CKD without diabetes and with an ACR below 70 mg/mmol whose systolic blood pressure is between 120–139 mmHg and their diastolic blood pressure below 90 mmHg.
Numerator – the number in the denominator whose systolic blood pressure is between 120–139 mmHg and their diastolic blood pressure below 90 mmHg.
Denominator – the number of adults with CKD without diabetes and with an ACR below 70 mg/mmol.
Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with coded CKD stages 3 to 5 with blood pressures below the recommended targets.
b) Proportion of adults with CKD and diabetes whose systolic blood pressure is between 120–129 mmHg and their diastolic blood pressure below 80 mmHg.
Numerator – the number in the denominator whose systolic blood pressure is between 120–129 mmHg and their diastolic blood pressure below 80 mmHg.
Denominator – the number of adults with CKD and diabetes.
Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with coded CKD stages 3 to 5 with blood pressures below the recommended targets.
c) Proportion of adults with CKD and an ACR of 70 mg/mmol or more whose systolic blood pressure is between 120–129 mmHg and their diastolic blood pressure below 80 mmHg.
Numerator – the number in the denominator whose systolic blood pressure is between 120–129 mmHg and their diastolic blood pressure below 80 mmHg.
Denominator – the number of adults with CKD and an ACR of 70 mg/mmol or more.
Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with coded CKD stages 3 to 5 with blood pressures below the recommended targets.

Outcomes

a) Prevalence of cardiovascular disease among people with CKD.
Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on comorbidities of renal patients, including angina, heart failure and atrial fibrillation.
b) Incidence of cardiovascular events for people with CKD.
Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on comorbidities of renal patients, including dates of heart failure, transient ischaemic attack, stroke and ST segment elevation myocardial infarction (STEMI).
c) Cardiovascular mortality rates among people with CKD.
Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on the cause of death of renal patients.
d) Incidence of end-stage kidney disease.
Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on the first date of renal replacement therapy or start of CKD stage 5 in renal patients.

What the quality statement means for different audiences

Service providers (general practices and secondary care services) ensure that systems are in place for adults with CKD to have their blood pressure maintained within the recommended range. This might involve having the equipment to take a blood pressure reading, using clinical IT systems to compare patients to the recommended range when entering a blood pressure reading, or flagging when patients need a blood pressure reading.
Healthcare professionals (GPs, nephrologists, nurses and pharmacists) monitor the blood pressure of adults with CKD and are aware of the recommended ranges. They support people to keep their blood pressure within the recommended range, for example, by starting or adjusting treatment, or advising on lifestyle changes.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults with CKD have their blood pressure maintained within the recommended range. They work with service providers to ensure that adults with CKD are identified, and have a blood pressure reading and any necessary support to maintain it within the recommended range.
Adults with CKD are supported to keep their blood pressure at a healthy level. If it is too high, their healthcare professional might offer medicine, or change the medicine they are taking, or suggest lifestyle changes, to help to control it.

Source guidance

Chronic kidney disease in adults: assessment and management (2014) NICE guideline CG182, recommendations 1.6.1 and 1.6.2.

Definitions of terms used in this quality statement

Adults with CKD
CKD is defined as abnormalities of kidney function or structure present for more than 3 months, with implications for health. This includes:
  • people with markers of kidney damage, including albuminuria (ACR more than 3 mg/mmol), urine sediment abnormalities, electrolyte and other abnormalities due to tubular disorders, abnormalities detected by histology, structural abnormalities detected by imaging or a history of kidney transplantation
  • people with a glomerular filtration rate (GFR) of less than 60 ml/min/1.73 m2 on at least 2 occasions separated by a period of at least 90 days (with or without markers of kidney damage).
(NICE’s guideline on chronic kidney disease in adults)
Recommended range
Blood pressure should be monitored and maintained within the following ranges:
  • In people with CKD aim to keep the systolic blood pressure below 140 mmHg (target range 120–139 mmHg) and the diastolic blood pressure below 90 mmHg.
  • In people with CKD and diabetes, and also in people with an ACR of 70 mg/mmol or more, aim to keep the systolic blood pressure below 130 mmHg (target range 120–129 mmHg) and the diastolic blood pressure below 80 mmHg.
[Adapted from NICE’s guideline on chronic kidney disease in adults, recommendations 1.6.1 and 1.6.2]
.

Statins for people with CKD

This quality statement is taken from the chronic kidney disease in adults quality standard. The quality standard defines clinical best practice in chronic kidney disease (CKD) care for adults and should be read in full.

Quality statement

Adults with chronic kidney disease (CKD) are offered atorvastatin 20 mg

Rationale

There is a higher risk of cardiovascular disease (CVD) in people with CKD. After discussing the risks and benefits of starting statin therapy with a healthcare professional, adults with CKD may choose statin therapy as an appropriate treatment to reduce their risk of first CVD events, or of future CVD events in adults who have already had an event, such as a heart attack or stroke. Statins are a clinically effective treatment for preventing CVD, and reducing the risks associated with CVD, for people who have CKD. Atorvastatin 20 mg is recommended as the preferred initial high-intensity statin because it is clinically and cost effective for the primary and secondary prevention of CVD.

Quality measures

Structure
a) Evidence of the availability of atorvastatin 20 mg within local service providers.
Data source: Local data collection, for example, local formularies.
b) Evidence of local systems to check whether adults with CKD are taking atorvastatin 20 mg and invite them to discuss starting treatment if not.
Data source: Local data collection, for example, service specifications.
Process
Proportion of adults with CKD who receive atorvastatin 20 mg.
Numerator – the number in the denominator who receive atorvastatin 20 mg.
Denominator – the number of adults with CKD.
Data source: Local data collection, for example, audit of health records. The National CKD Audit reports the percentage of people with coded CKD stages 3 to 5 who are on a statin.

Outcomes

a) Prevalence of cardiovascular disease among people with CKD.
Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on comorbidities of renal patients, including angina, heart failure and atrial fibrillation.
b) Incidence of cardiovascular events for people with CKD.
Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on comorbidities of renal patients, including dates of heart failure, transient ischaemic attack, stroke and ST segment elevation myocardial infarction (STEMI).
c) Cardiovascular mortality rates among people with CKD.
Data source: Local data collection, for example, audit of health records. The UK Renal Registry collects data on the cause of death of renal patients.
d) Proportion of people with CKD with a greater than 40% reduction in non‑high‑density lipoprotein cholesterol.
Data source: Local data collection, for example, audit of health records.

What the quality statement means for different audiences

Service providers (general practices and secondary care services, such as renal, cardiology, diabetes and rheumatology clinics) ensure that systems are in place for adults with CKD to be offered atorvastatin 20 mg. For example, this may be done through incorporating treatment algorithms into software applications to provide users with patient-specific recommendations on treatment.
Health professionals (GPs, nephrologists, cardiologists, diabetologists, rheumatologists, nurses and pharmacists) check whether adults with CKD are taking a statin, and discuss the risks and benefits of starting statin therapy if not. They offer atorvastatin 20 mg and increase the dose if an adequate response to treatment is not achieved and eGFR is 30 ml/min/1.73 m2 or more. If a person is not able to tolerate atorvastatin 20 mg or reports adverse effects, they discuss alternative options such as stopping the statin or changing the dose or type of statin.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults with CKD are offered atorvastatin 20 mg. Commissioners may do this by seeking evidence of practice through clinical audits.
Adults with CKD are at a higher risk of heart attacks and strokes. To help reduce the risk they are offered a type of medicine called a statin, which lowers the level of cholesterol (sometimes called lipids) in the blood. If their cholesterol level does not decrease enough, they may change to a higher dose. If the statin causes any side effects, their doctor might ask them to stop taking it for a while to check that they are caused by the statin. Their doctor might discuss reducing the dose or changing to a different statin.

Source guidance

Definitions of terms used in this quality statement

Adults with CKD
CKD is defined as abnormalities of kidney function or structure present for more than 3 months, with implications for health. This includes:
  • people with markers of kidney damage, including albuminuria (ACR more than 3 mg/mmol), urine sediment abnormalities, electrolyte and other abnormalities due to tubular disorders, abnormalities detected by histology, structural abnormalities detected by imaging or a history of kidney transplantation
  • people with a glomerular filtration rate (GFR) of less than 60 ml/min/1.73 m2 on at least 2 occasions separated by a period of at least 90 days (with or without markers of kidney damage).
(NICE’s guideline on chronic kidney disease in adults)

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Grouping of statins used in this interactive flowchart

Reduction in low-density lipoprotein cholesterol
Dose (mg/day)
5
10
20
40
80
Fluvastatin
21%20%–30%: low intensity
27%
33%31%–40%: medium intensity
Pravastatin
20%
24%
29%
Simvastatin
27%
32%
37%
42%Above 40%: high intensity,Advice from the MHRA: there is an increased risk of myopathy associated with high-dose (80 mg) simvastatin. The 80-mg dose should be considered only in patients with severe hypercholesterolaemia and high risk of cardiovascular complications who have not achieved their treatment goals on lower doses, when the benefits are expected to outweigh the potential risks.
Atorvastatin
37%
43%
49%
55%
Rosuvastatin
38%
43%
48%
53%
The information used to make the table is from Law MR, Wald NJ, Rudnicka AR (2003) Quantifying effect of statins on low density lipoprotein cholesterol, ischaemic heart disease, and stroke: systematic review and meta-analysis. BMJ 326: 1423.
Offer atorvastatin 20 mg for the primary or secondary prevention of cardiovascular disease to people with chronic kidney disease.
  • Increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved (see follow-up and monitoring) and estimated glomerular filtration rate is 30 ml/min/1.73m2 or more.
  • Agree the use of higher doses with a renal specialist if estimated glomerular filtration rate is less than 30ml/min/1.73m2.
For further information, see what NICE says on chronic kidney disease.
Give advice on diet and physical activity in line with national recommendations (see NHS Choices). For more information, see what NICE says on lifestyle advice on diet and physical activity.
The following recommendation is an extract from NICE technology appraisal guidance on ezetimibe for treating primary heterozygous-familial and non-familial hypercholesterolaemia.
Ezetimibe monotherapy is recommended as an option for treating primary (heterozygous-familial or non-familial) hypercholesterolaemia in adults in whom initial statin therapy is contraindicated.
NICE has written information for the public explaining its guidance on ezetimibe.

Glossary

cardiovascular disease
adults who are disadvantaged include (but are not limited to) those on a low income (or who are members of a low-income family), those on benefits, those living in public or social housing, some members of black and minority ethnic groups, those with a mental health problem, those with a learning disability, those who are institutionalised (including those serving a custodial sentence) and those who are homeless
glycated haemoglobin
high-density lipoprotein
the following doses for statins are high intensity, based on the percentage reduction in low density lipoprotein (LDL) cholesterol they can produce: atorvastatin 20–80 mg; rosuvastatin 10–40 mg; simvastatin 80 mg
if someone has a 20% or higher risk of a first cardiovascular event in the next 10 years they are deemed at high risk of cardiovascular disease
for the purpose of this interactive flowchart, statins are grouped into 3 different intensity categories according to the percentage reduction in low-density lipoprotein cholesterol: low intensity if the reduction is from 20% to 30%; medium intensity if the reduction is from 31% to 40%; and high intensity if the reduction is above 40%
low-density lipoprotein
low-density lipoprotein cholesterol

Paths in this pathway

Pathway created: July 2014 Last updated: July 2017

© NICE 2017

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