× NICE uses cookies to make the site better.  Learn more
A-Z
Topics
Latest

Cardiovascular disease prevention

About

What is covered

This pathway 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 pathway

26 September 2016 Pathway updated to clarify what is meant by high-intensity statin treatment.
20 September 2016 Link to NICE pathway on multimorbidity added.
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 quality standard added.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. 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 pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

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.

Short Text

Everything NICE has said on cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease in an interactive flowchart.

What is covered

This pathway 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 pathway

26 September 2016 Pathway updated to clarify what is meant by high-intensity statin treatment.
20 September 2016 Link to NICE pathway on multimorbidity added.
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 quality standard added.

Sources

NICE guidance and other sources used to create this pathway.

Quality standards

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.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. 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 pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

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.

Supporting information

Grouping of statins used in this pathway

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 in this pathway) 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.
NICE has produced a pathway on chronic kidney disease.
Give advice on diet and physical activity in line with national recommendations (see NHS Choices). For more information see lifestyle advice on diet and physical activity in the NICE pathway on diet.
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
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
for the purpose of this pathway, 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: November 2016

© NICE 2016

Recently viewed