Cardiovascular disease: risk assessment and reduction, including lipid modification

National Institute for Health and Care Excellence


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Identifying and assessing cardiovascular disease (CVD) risk

Identifying people for full formal risk assessment

  • For the primary prevention of CVD in primary care, use a systematic strategy to identify people who are likely to be at high risk
  • Prioritise people on the basis of an estimate of their CVD risk before a full formal risk assessment. Estimate their CVD risk using CVD risk factors already recorded in primary care electronic medical records
  • People older than 40 should have their estimate of CVD risk reviewed on an ongoing basis
  • Prioritise people for a full formal risk assessment if their estimated 10-year risk of CVD is 10% or more
  • Discuss the process of risk assessment with the person identified as being at risk, including the option of declining any formal risk assessment
  • Do not use opportunistic assessment as the main strategy in primary care to identify CVD risk in unselected people

Full formal risk assessment

  • Be aware that all CVD risk assessment tools can provide only an approximate value for CVD risk. Interpretation of CVD risk scores should always reflect informed clinical judgement
  • Use the QRISK2 risk assessment tool to assess CVD risk for the primary prevention of CVD in people up to and including age 84 years
  • Do not use a risk assessment tool to assess CVD risk in people with type 1 diabetes. See Primary prevention for people with type 1 diabetes (below) for advice on treatment with statins for people with type 1 diabetes
  • Use the QRISK2 risk assessment tool to assess CVD risk in people with type 2 diabetes
  • Do not use a risk assessment tool to assess CVD risk in people with an estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m2 and/or albuminuria.* These people are at increased risk of CVD
  • Complete as many fields of the risk assessment tool as possible
  • Routinely record ethnicity, body mass index and family history of premature CVD in medical records
  • Consider socioeconomic status as an additional factor that contributes to CVD risk
  • Do not use a risk assessment tool for people with pre-existing CVD
  • Do not use a risk assessment tool for people who are at high risk of developing CVD because of familial hypercholesterolaemia or other inherited disorders of lipid metabolism
  • When using the 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 and
    • may not be included in calculated risk scores
  • Recognise that standard CVD risk scores will underestimate risk in people who have additional risk because of underlying medical conditions or treatments. These groups include:
    • people treated for HIV
    • people with serious mental health problems
    • people taking medicines that can cause dyslipidaemia such as antipsychotic medication, corticosteroids or immunosuppressant drugs
    • people with autoimmune disorders such as systemic lupus erythematosus, and other systemic inflammatory disorders
  • Recognise that CVD risk will be underestimated in people who are already taking antihypertensive or lipid modification therapy, or who have recently stopped smoking. Use clinical judgement to decide on further treatment of risk factors in people who are below the CVD risk threshold for treatment
  • Severe obesity (body mass index greater than 40 kg/m2) increases CVD risk. Take this into account when using risk scores to inform treatment decisions in this group
  • Consider people aged 85 or older to be at increased risk of CVD because of age alone, particularly people who smoke or have raised blood pressure

Communication about risk assessment and treatment

  • NICE has produced guidance on the components of good patient experience in adult NHS services. These include recommendations on the communication of risk. Follow the recommendations in Patient experience in adult NHS services (NICE CG138)
  • Use everyday, jargon-free language to communicate information on risk. If technical terms are used, explain them clearly
  • Set aside adequate time during the consultation to provide information on risk assessment and to allow any questions to be answered. Further consultation may be required
  • Document the discussion relating to the consultation on risk assessment and the person's decision
  • Offer people information about their absolute risk of CVD and about the absolute benefits and harms of an intervention over a 10-year period. This information should be in a form that:
    • presents individualised risk and benefit scenarios and
    • presents the absolute risk of events numerically and
    • uses appropriate diagrams and text
  • To encourage the person to participate in reducing their CVD risk:
    • find out what, if anything, the person has already been told about their CVD risk and how they feel about it
    • explore the person's beliefs about what determines future health (this may affect their attitude to changing risk)
    • assess their readiness to make changes to their lifestyle (diet, physical activity, smoking and alcohol consumption), to undergo investigations and to take long-term medication
    • assess their confidence in making changes to their lifestyle, undergoing investigations and taking medication
    • inform them of potential future management based on current evidence and best practice
    • involve them in developing a shared management plan
    • check with them that they have understood what has been discussed
  • If the person's CVD risk is at a level where intervention is recommended but they decline the offer of treatment, advise them that their CVD risk should be reassessed again in the future. Record their choice in their medical notes

Lifestyle modifications for the primary and secondary prevention of CVD

Cardioprotective diet

  • Advise people at high risk of or with CVD to eat a diet in which total fat intake is 30% or less of total energy intake, saturated fats are 7% or less of total energy intake, intake of dietary cholesterol is less than 300 mg/day and where possible saturated fats are replaced by mono-unsaturated and polyunsaturated fats
  • Advise people at high risk of or with CVD to:
    • reduce their saturated fat intake
    • increase their mono-unsaturated fat intake with olive oil, rapeseed oil or spreads based on these oils and to use them in food preparation
  • Further information and advice on healthy cooking methods can be found at NHS Choices
  • Advise people at high risk of or with CVD to do all of the following:
    • choose wholegrain varieties of starchy food
    • reduce their intake of sugar and food products containing refined sugars including fructose
    • eat at least 5 portions of fruit and vegetables per day
    • eat at least 2 portions of fish per week, including a portion of oily fish
    • eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week
  • Advise pregnant women to limit their oily fish to no more than 2 portions per week and to avoid marlin, shark and swordfish
  • Take account of a person's individual circumstances—for example, drug therapy, comorbidities and other lifestyle modifications when giving dietary advice
  • Advise and support people at high risk of or with CVD to achieve a healthy diet in line with Behaviour change: the principles for effective interventions (NICE public health guidance 6)  

Physical activity

  • Advise people at high risk of or with CVD to do the following every week:
    • at least 150 minutes of moderate intensity aerobic activity or
    • 75 minutes of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity in line with national guidance for the general population
  • Advise people to do muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance for the general population
  • Encourage people who are unable to perform moderate-intensity physical activity because of comorbidity, medical conditions or personal circumstances to exercise at their maximum safe capacity
  • Advice about physical activity should take into account the person's needs, preferences and circumstances. Agree goals and provide the person with written information about the benefits of activity and local opportunities to be active, in line with Four commonly used methods to increase physical activity (NICE public health guidance 2)

Combined interventions (diet and physical activity)

  • Give advice on diet and physical activity in line with national recommendations

Weight management

  • Offer people at high risk of or with CVD who are overweight or obese appropriate advice and support to work towards achieving and maintaining a healthy weight, in line with Obesity (NICE CG43) 

Alcohol consumption

  • Be aware that men should not regularly drink more than 3–4 units a day and women should not regularly drink more than 2–3 units a day. People should avoid binge drinking

Smoking cessation

  • Advise all people who smoke to stop, in line with Smoking cessation services (NICE public health guidance 10)
  • Offer people who want to stop smoking support and advice, and referral to an intensive support service (for example, the NHS Stop Smoking Services)
  • If a person is unable or unwilling to accept a referral to an intensive support service, offer them pharmacotherapy in line with Smoking cessation services and Varenicline for smoking cessation

Plant stanols and sterols

  • Do not advise any of the following to take plant stanols or sterols for the prevention of CVD:
    • people who are being treated for primary prevention
    • people who are being treated for secondary prevention
    • people with CKD
    • people with type 1 diabetes
    • people with type 2 diabetes

Lipid modification therapy for the primary and secondary prevention of CVD

  • Be aware that when deciding on lipid modification therapy for the prevention of CVD, drugs are preferred for which there is evidence in clinical trials of a beneficial effect on CVD morbidity and mortality
  • When a decision is made to prescribe a statin use a statin of high intensity and low acquisition cost

Lipid measurement and referral

  • Measure both total and high-density lipoprotein (HDL) cholesterol to achieve the best estimate of CVD risk
  • Before starting lipid modification therapy for the primary prevention of CVD, take at least 1 lipid sample to measure a full lipid profile. This should include measurement of total cholesterol, HDL cholesterol, non-HDL cholesterol and triglyceride concentrations. A fasting sample is not needed
  • Use the clinical findings, lipid profile and family history to judge the likelihood of a familial lipid disorder rather than the use of strict lipid cut-off values alone
  • Exclude possible common secondary causes of dyslipidaemia (such as excess alcohol, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome) before referring for specialist review
  • Consider the possibility of familial hypercholesterolaemia and investigate as described in Familial hypercholesterolaemia (NICE CG71) if they have:
    • a total cholesterol concentration more than 7.5 mmol/litre and
    • a family history of premature coronary heart disease
  • Arrange for specialist assessment of people with a total cholesterol concentration of more than 9.0 mmol/litre or a non-HDL cholesterol concentration of more than 7.5 mmol/litre even in the absence of a first-degree family history of premature coronary heart disease
  • Refer for urgent specialist review if a person has a triglyceride concentration of more than 20 mmol/litre that is not a result of excess alcohol or poor glycaemic control
  • In people with a triglyceride concentration between 10 and 20 mmol/litre:
    • repeat the triglyceride measurement with a fasting test (after an interval of 5 days, but within 2 weeks) and
    • review for potential secondary causes of hyperlipidaemia and
    • seek specialist advice if the triglyceride concentration remains above 10 mmol/litre
  • In people with a triglyceride concentration between 4.5 and 9.9 mmol/litre:
    • be aware that the CVD risk may be underestimated by risk assessment tools and
    • optimise the management of other CVD risk factors present and
    • seek specialist advice if non-HDL cholesterol concentration is more than 7.5 mmol/litre

Statins for the prevention of CVD

  • The decision whether to start statin therapy should be made after an informed discussion between the clinician and the person about the risks and benefits of statin treatment, taking into account additional factors such as potential benefits from lifestyle modifications, informed patient preference, comorbidities, polypharmacy, general frailty and life expectancy
  • Before starting statin treatment perform baseline blood tests and clinical assessment, and treat comorbidities and secondary causes of dyslipidaemia. Include all of the following in the assessment:
    • smoking status
    • alcohol consumption
    • blood pressure
    • body mass index or other measure of obesity
    • total cholesterol, non-HDL cholesterol, HDL cholesterol and triglycerides
    • HbA1c
    • renal function and eGFR
    • transaminase level (alanine aminotransferase or aspartate aminotransferase)
    • thyroid-stimulating hormone

Primary prevention

  • Before offering statin treatment for primary prevention, discuss the benefits of lifestyle modification and optimise the management of all other modifiable CVD risk factors if possible
  • Recognise that people may need support to change their lifestyle. To help them do this, refer them to programmes such as exercise referral schemes
  • Offer people the opportunity to have their risk of CVD assessed again after they have tried to change their lifestyle
  • If lifestyle modification is ineffective or inappropriate offer statin treatment after risk assessment
  • Offer atorvastatin 20 mg for the primary prevention of CVD to people who have a 10% or greater 10-year risk of developing CVD. Estimate the level of risk using the QRISK2 assessment tool
  • For people 85 years or older consider atorvastatin 20 mg as statins may be of benefit in reducing the risk of non-fatal myocardial infarction. Be aware of factors that may make treatment inappropriate

Secondary prevention

  • Start statin treatment in people with CVD with atorvastatin 80 mg. Use a lower dose of atorvastatin if any of the following apply:
    • potential drug interactions
    • high risk of adverse effects
    • patient preference
  • Do not delay statin treatment in secondary prevention to manage modifiable risk factors
  • If a person has acute coronary syndrome, do not delay statin treatment. Take a lipid sample on admission and about 3 months after the start of treatment

Primary prevention for people with type 1 diabetes

  • Consider statin treatment for the primary prevention of CVD in all adults with type 1 diabetes
  • Offer statin treatment for the primary prevention of CVD to adults with type 1 diabetes who:
    • are older than 40 years or
    • have had diabetes for more than 10 years or
    • have established nephropathy or
    • have other CVD risk factors
  • Start treatment for adults with type 1 diabetes with atorvastatin 20 mg

Primary prevention for people with type 2 diabetes

  • Offer atorvastatin 20 mg for the primary prevention of CVD to people with type 2 diabetes who have a 10% or greater 10-year risk of developing CVD. Estimate the level of risk using the QRISK2 assessment tool

People with CKD

  • Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD:§
    • increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved and eGFR is 30 ml/min/1.73 m2 or more
    • agree the use of higher doses with a renal specialist if eGFR is less than 30 ml/min/1.73 m2

Follow-up of people started on statin treatment

  • Measure total cholesterol, HDL cholesterol and non-HDL cholesterol in all people who have been started on high-intensity statin treatment at 3 months of treatment and aim for a greater than 40% reduction in non-HDL cholesterol. If a greater than 40% reduction in non-HDL cholesterol is not achieved:
    • discuss adherence and timing of dose
    • optimise adherence to diet and lifestyle measures
    • consider increasing the dose if started on less than atorvastatin 80 mg and the person is judged to be at higher risk because of comorbidities, risk score or using clinical judgement
  • Provide annual medication reviews for people taking statins:
    • use these reviews to discuss medicines adherence and lifestyle modification and address CVD risk factors
    • consider an annual non-fasting blood test for non-HDL cholesterol to inform the discussion
  • Discuss with people who are stable on a low- or middle-intensity statin the likely benefits and potential risks of changing to a high-intensity statin when they have a medication review and agree with the person whether a change is needed

Advice and monitoring for adverse effects

  • Advise people who are being treated with a statin:
    • that other drugs, some foods (for example, grapefruit juice) and some supplements may interfere with statins and
    • to always consult the patient information leaflet, a pharmacist or prescriber for advice when starting other drugs or thinking about taking supplements
  • Remind the person to restart the statin if they stopped taking it because of drug interactions or to treat intercurrent illnesses
  • Before offering a statin, ask the person if they have had persistent generalised unexplained muscle pain, whether associated or not with previous lipid-lowering therapy. If they have, measure creatine kinase levels:
    • if creatine kinase levels are more than 5 times the upper limit of normal, re-measure creatine kinase after 7 days. If creatine kinase levels are still 5 times the upper limit of normal, do not start statin treatment
    • if creatine kinase levels are raised but less than 5 times the upper limit of normal, start statin treatment at a lower dose
  • Advise people who are being treated with a statin to seek medical advice if they develop muscle symptoms (pain, tenderness or weakness). If this occurs, measure creatine kinase
  • If people report muscle pain or weakness while taking a statin, explore other possible causes of muscle pain or weakness and raised creatine kinase if they have previously tolerated statin therapy for more than 3 months
  • Do not measure creatine kinase levels in asymptomatic people who are being treated with a statin
  • Measure baseline liver transaminase enzymes (alanine aminotransferase or aspartate aminotransferase) before starting a statin. Measure liver transaminase within 3 months of starting treatment and at 12 months, but not again unless clinically indicated
  • Do not routinely exclude from statin therapy people who have liver transaminase levels that are raised but are less than 3 times the upper limit of normal
  • Do not stop statins because of an increase in blood glucose level or HbA1c
  • Statins are contraindicated in pregnancy:
    • advise women of childbearing potential of the potential teratogenic risk of statins and to stop taking them if pregnancy is a possibility
  • Advise women planning pregnancy to stop taking statins 3 months before they attempt to conceive and to not restart them until breastfeeding is finished

Intolerance of statins

  • If a person is not able to tolerate a high-intensity statin aim to treat with the maximum tolerated dose
  • Tell the person that any statin at any dose reduces CVD risk. If someone reports adverse effects when taking high-intensity statins discuss the following possible strategies with them:
    • stopping the statin and trying again when the symptoms have resolved to check if the symptoms are related to the statin
    • reducing the dose within the same intensity group
    • changing the statin to a lower intensity group
  • Seek specialist advice about options for treating people at high risk of CVD such as those with CKD, type 1 diabetes, type 2 diabetes or genetic dyslipidaemias, and those with CVD, who are intolerant to 3 different statins. Advice can be sought for example, by telephone, virtual clinic or referral

Adherence to statin therapy

  • Do not offer coenzyme Q10 or vitamin D to increase adherence to statin treatment

Fibrates for preventing CVD

  • Do not routinely offer fibrates for the prevention of CVD to any of the following:
    • people who are being treated for primary prevention
    • people who are being treated for secondary prevention
    • people with CKD
    • people with type 1 diabetes
    • people with type 2 diabetes

Nicotinic acid for preventing CVD

  • Do not offer nicotinic acid (niacin) for the prevention of CVD to any of the following:
    • people who are being treated for primary prevention
    • people who are being treated for secondary prevention
    • people with CKD
    • people with type 1 diabetes
    • people with type 2 diabetes

Bile acid sequestrants (anion exchange resins) for preventing CVD

  • Do not offer a bile acid sequestrant (anion exchange resin) for the prevention of CVD to any of the following:
    • people who are being treated for primary prevention
    • people who are being treated for secondary
    • prevention people with CKD
    • people with type 1 diabetes
    • people with type 2 diabetes

Omega-3 fatty acid compounds for preventing CVD

  • Do not offer omega-3 fatty acid compounds for the prevention of CVD to any of the following:
    • people who are being treated for primary prevention
    • people who are being treated for secondary prevention
    • people with CKD
    • people with type 1 diabetes
    • people with type 2 diabetes
  • Tell people that there is no evidence that omega-3 fatty acid compounds help to prevent CVD

Combination therapy for preventing CVD

  • Do not offer the combination of a bile acid sequestrant (anion exchange resin), fibrate, nicotinic acid or omega‑3 fatty acid compound with a statin for the primary or secondary prevention of CVD

Ezetimibe

  • People with primary hypercholesterolaemia should be considered for ezetimibe treatment in line with Ezetimibe for the treatment of primary (heterozygous-familial and non-familial) hypercholesterolaemia

* People on renal replacement therapy are outside the scope of this guideline.

† See full guideline for statin classification.

‡ At the time of publication (July 2014), atorvastatin did not have a UK marketing authorisation for this indication. 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.

§ See Chronic kidney disease: early identification and management of chronic kidney disease in adults in primary and secondary care (NICE CG182) for CKD classification. People on renal replacement therapy are outside the scope of this guideline.

References

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/CG181

National Institute for Health and Care Excellence. Cardiovascular disease: risk assessment and reduction, including lipid modification. July 2014, updated August 2016.
First included: July 14.


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