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Overview

This Guidelines summary covers key recommendations from national guidance on lipid management for the primary and secondary prevention of cardiovascular disease (CVD), including:

  • treatment pathway for primary and secondary prevention of CVD
  • management
  • primary prevention risk assessment
  • special patient populations
  • statin intensity table
  • monitoring
  • titration threshold/targets
  • specialist services
  • triglycerides
  • statin intolerance.

View this summary online at guidelines.co.uk/456226.article

Lipid management pathway

Algorithm 1: Lipid management pathway

NHS Lipid management pathway

NHS. Summary of national guidance for lipid management for primary and secondary prevention of CVD. NHS, 2021.

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Management

This guidance applies to new patients and may also be taken into consideration for those already on statins at their annual review.

  • If 40% reduction of non-high-density lipoprotein cholesterol (non-HDL-C) is not achieved, offer high-intensity statins
  • Discuss with people who are stable on a low- or medium-intensity statin the likely benefits and potential risk of side effects if changed to a high-intensity statin when they have a medication review and agree with the person whether a change is needed
  • If statin therapy is contraindicated, not tolerated, or not effective, consider first ezetimibe, then ezetimibe/bempedoic acid, then proprotein convertase subtilisin kexin 9 inhibitor (PCSK9i)
  • Use of ezetimibe/bempedoic acid is not precluded when prior low-dose statin is used due to intolerance to higher-intensity statin. Check the summary of product characteristics for interactions
  • Do not offer a fibrate, nicotinic acid, bile acid binder or omega-3 fatty acids alone or in combination with statin, for the prevention of CVD. Check the NICE guideline on Cardiovascular disease: risk assessment and reduction, including lipid modification for exceptions.

Primary prevention risk assessment

  • QRISK3 is the current version of the QRISK calculator
    • do not use this risk assessment tool for people with established CVD or those who are at high risk of developing CVD because of familial hypercholesterolaemia or other inherited disorders of lipid metabolism
    • do not use a risk assessment tool to assess CVD risk in people with type 1 diabetes, or estimated glomerular filtration rate (eGFR) less than 60 ml per minute per 1.73 m2 and/or albuminuria
    • consider people aged 85 or over at increased risk of CVD because of age alone, particularly people who smoke or have raised blood pressure.

Additional risk factors

  • Standard CVD risk scores including QRISK may underestimate risk in people who have additional risk because of underlying medical conditions or treatments. These groups include the following groups of people:
    • severe obesity (body mass index over 40 kg/m2) increases CVD risk
    • treated for HIV
    • serious mental health problems
    • taking medicines that can cause dyslipidaemia such as antipsychotic medication, corticosteroids, or immunosuppressant drugs
    • autoimmune disorders such as systemic lupus erythematosus, and other systemic inflammatory disorders
    • non-diabetic hyperglycaemia
    • significant hypertriglyceridaemia (fasting triglycerides 4.5–9.9 mmol per litre)
    • recent risk factor changes, for example, quit smoking, blood pressure, or lipid treatment
  • Consider socioeconomic status as an additional factor contributing to CVD risk
  • If QRISK less than 10% over the next 10 years, give lifestyle advice and ensure regular review of CVD risk in line with guidance.

Special patient populations

Type 1 diabetes

  • While NICE recommends offering statins to patients with type 1 diabetes as detailed in the algorithm, it also states to consider statins in all adults with type 1 diabetes.

Chronic kidney disease

  • Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with chronic kidney disease (eGFR less than 60 ml per min per 1.73m2 and/or albuminuria)
  • Increase the dose if a greater than 40% reduction in non-HDL-C is not achieved and eGFR is 30 ml per min per 1.73m2 or more
  • Agree the use of higher doses with a renal specialist if eGFR is less than 30 ml per min per 1.73m2.

Statin intensity

Table 1: Statin intensity table

 

Approximate reduction in LDL-C

Statin dose mg/day

5

10

20

40

80

Fluvastatin

   

21%[A]

27%[A]

33%[B]

Pravastatin

 

20%[A]

24%[A]

29%[A]

 

Simvastatin

 

27%[A]

32%[B]

37%[B]

42%[D]

Atorvastatin

 

37%[B]

43%[C]

49%[C]

55%[C]

Rosuvastatin

38%[B]

43%[C]

48%[C]

53%[C]

 

Atorvastatin + ezetimibe 10 mg

 

52%[C]

54%[C]

57%[C]

61%[C]

[A] Low-intensity statins—will produce an LDL-C reduction of 20–30%

[B] Medium-intensity statins—will produce an LDL-C reduction of 31–40%

[C] High-intensity statins—will produce an LDL-C reduction above 40%

[D] Simvastatin—80 mg is not recommended due to muscle toxicity

LDL-C=low-density lipoprotein cholesterol

  • Rosuvastatin may be used as an alternative to atorvastatin if compatible with other drug therapy. Lower starting dose maybe needed in some—see British National Formulary (BNF)
  • Low/medium intensity statins and should only be used in intolerance or drug interactions
  • Ezetimibe when combined with any statin is likely to give greater reduction in non-HDL-C/low-density lipoprotein cholesterol (LDL-C) than doubling the dose of the statin
  • PCSK9i alone, or in combination with statins or ezetimibe, produces an additional LDL-C reduction of approximately 50% (range 25–70%)
  • Bempedoic acid when combined with ezetimibe produces an additional LDL-C reduction of approximately 28% (range 22–33%) but the long-term treatment effect of bempedoic acid is uncertain.

Monitoring

Baseline measurements

  • In addition to full lipid profile, measure renal, thyroid, and liver profiles (including albumin) and HbA1c to exclude secondary causes and comorbidities
  • Measure baseline liver transaminase (alanine aminotransferase [ALT] or aspartate aminotransferase [AST]) before starting a statin
  • Measure creatine kinase (CK) if unexplained muscle pain before starting a statin. CK should not be measured routinely, especially if a patient is asymptomatic.

Table 2: Baseline measurements table

 

Primary prevention

Secondary prevention

 

Lipid profile

ALT or AST

Lipid profile

ALT or AST

Baseline



3 months




6–9 months

If <40% non-HDL-C reduction, up titration required. Repeat full lipid profile and ALT or AST within 3 months of each up-titration of statin dose or addition of ezetimibe as required

12 months



Yearly

[A]

 

[A]

 

[A] Consider an annual non-fasting full lipid profile to inform the discussion around effectiveness of lipid-lowering therapy, and any medicines non-adherence

Provide annual medication reviews for people taking statins to discuss effectiveness of therapy, medicines adherence, lifestyle modification and address CVD risk factors.

Abbreviations: ALT=alanine aminotransferase; AST=aspartate aminotransferase; non-HDL-C=non-high-density lipoprotein cholesterol

Monitoring

  • Repeat full lipid profile is non-fasting
  • Measure liver transaminase within 3 months of starting treatment, then within 3 months of every additional up titration, and then again at 12 months, but not again unless clinically indicated
  • If ALT or AST are greater than three times the upper limit of normal, do not initiate a statin, or discontinue statin therapy already prescribed. Repeat the liver function tests in a month
  • If ALT or AST are elevated, but are less than three times the upper limit of normal, then:
    • continue the statin and repeat in a month
    • if they remain elevated but are less than three times the upper limit of normal then continue statin and repeat again in 6 months.

Titration threshold/targets

Table 3: Titration thresholds

 

NICE titration threshold

JBS3

Primary prevention

Intensify lipid-lowering therapy if non-HDL-C reduction from baseline is <40%

Non-HDL-C <2.5 mmol/L (LDL-C <1.8 mmol/L)

Secondary prevention

FH

Optimise lipid-lowering therapy to achieve at least 50% reduction in LDL-C (or non-HDL-C)

 

If baseline cholesterol is unknown in the setting of secondary prevention, use the Joint British Societies’ JBS3 consensus recommendation

Non-HDL-C=TC minus HDL-C; LDL-C=non-HDL-C minus (fasting triglycerides[A]/2.2)

[A] Valid only when fasting triglycerides are less than 4.5 mmol/L

Abbreviations: FH=familial hypercholesterolaemia; LDL-C=low-density lipoprotein cholesterol; non-HDL-C=non-high-density lipoprotein cholesterol

Triglycerides

Table 4: Triglyceride concentrations

Triglyceride concentration
Action

>20 mmol/L

Refer to lipid clinic for urgent specialist review if not a result of excess alcohol or poor glycaemic control. At risk of acute pancreatitis

10–20 mmol/L

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. Seek specialist advice if the triglyceride concentration remains >10 mmol/L. At risk of acute pancreatitis

4.5–9.9 mmol/L

If non-fasting triglycerides >4.5 mmol/L, repeat with a fasting triglyceride measurement

 

Be aware that the CVD risk may be underestimated by risk assessment tools, optimise the management of other CVD risk factors present, and seek specialist advice if non-HDL-C concentration >7.5 mmol/L

Abbreviations: CVD=cardiovascular disease; non-HDL-C=non-high-density lipoprotein cholesterol

Statin intolerance

  • Statin intolerance is defined as the presence of clinically significant adverse effects from statin therapy that are considered to represent an unacceptable risk to the patient or that may result in adherence to therapy being compromised
  • For people who are intolerant of the recommended statin treatment, see the NHSE AAC statin intolerance algorithm.

 

Full guideline:

NHS England. Summary of national guidance for lipid management for primary and secondary prevention of CVD. July 2021.

Available at: england.nhs.uk/aac/publication/summary-of-national-guidance-for-lipid-management/

Contains public sector information licensed under the Open Government Licence v3.0

Published date: July 2021.