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Summary for primary care

Cardiovascular Disease: Risk Assessment and Reduction, Including Lipid Modification

NICE

Latest Guidance Updates

14 December 2023: restructured sections and amended recommendations throughout. Refer to the update information in the full guideline.

24 May 2023: NICE reviewed the evidence on risk assessment tools for primary prevention of CVD, cardioprotective diets, and statin treatment for primary and secondary prevention of CVD. Recommendations for people with type 1 diabetes and chronic kidney disease, and for follow up of people started on statin treatment, have not changed.

Overview

This updated Guidelines summary covers the assessment and care of adults who are at risk of, or who have, cardiovascular disease (CVD), such as heart disease or stroke.

This summary includes recommendations intended for use in primary care. For secondary care recommendations, refer to the secondary care summary.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Identifying and Assessing Cardiovascular Disease Risk for People Without Established Cardiovascular Disease

Identifying People for Full Formal Risk Assessment

  • For the primary prevention of cardiovascular disease (CVD) in primary care, use a systematic strategy to identify people who are likely to be at high risk of CVD. 
  • Prioritise people based on an estimate of their CVD risk before doing a full formal risk assessment. Estimate their CVD risk using CVD risk factors already recorded in primary care electronic medical records. 
  • Review estimates of CVD risk on an ongoing basis for people over 40.
  • 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

  • Use the QRISK3 tool to calculate the estimated CVD risk within the next 10 years for people aged between 25 and 84 without CVD.
  • Use the QRISK3 tool for people with type 2 diabetes aged between 25 and 84.

    Until electronic clinical systems in which QRISK2 is embedded are updated with QRISK3, it may be necessary to use QRISK2. 

    When assessing risk for people taking corticosteroids or atypical antipsychotics or people with systemic lupus erythematosus, migraine, severe mental illness or erectile dysfunction, use QRISK3 (the online version of QRISK3, if necessary) because QRISK2 does not take these risk factors into account and so may underestimate the 10‑year CVD risk in these populations.

  • Do not use a risk assessment tool for people who are at high risk of CVD, including people with:
    • type 1 diabetes (see the section on primary prevention of CVD for people with type 1 diabetes)
    • an estimated glomerular filtration rate less than 60 ml/min/1.73 m2 and/or albuminuria (see the section on primary and secondary prevention of CVD for people with CKD)
    • familial hypercholesterolaemia (see NICE's guideline on familial hypercholesterolaemia) or other inherited disorders of lipid metabolism.
  • Recognise that CVD risk tools may underestimate risk in certain groups of people, including but not limited to:
    • people treated for HIV
    • people already taking medicines to treat CVD risk factors
    • people who have recently stopped smoking
    • people taking medicines that can cause dyslipidaemia such as immunosuppressant drugs
    • people with severe mental illness
    • people with autoimmune disorders, and other systemic inflammatory disorders.
  • 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, Lifestyle Changes, and Treatment

  • Follow the recommendations on communication in NICE's guidelines on patient experience in adult NHS services and shared decision making.
  • Set aside adequate time during the consultation to provide information on risk assessment and to answer any questions. Arrange for further consultation if needed.
  • 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.
  • Consider using a lifetime risk tool such as QRISK3-lifetime to inform discussions on CVD risk and to motivate lifestyle changes, particularly for people with a 10‑year QRISK3 score less than 10%, and people under 40 who have CVD risk factors.
  • 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 to make changes to their lifestyle, undergo investigations and take medication
    • inform them of potential future management options based on current evidence and best practice
    • involve them in developing a shared management plan
    • check 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 records. 

Aspirin for Primary Prevention of Cardiovascular Disease

  • Do not routinely offer aspirin for primary prevention of CVD.
For guidance on using aspirin to prevent venous thromboembolism in over 16s in hospital, see NICE's guideline on venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism.

Lifestyle Changes for the Primary and Secondary Prevention of Cardiovascular Disease

Behaviour Change

Healthy Eating 

For advice on healthy eating, see the NHS eat well guide.

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, 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. 
  • Take account of a person's individual circumstances—for example, drug therapy, comorbidities and other lifestyle modifications when giving dietary advice. 

Physical Activity

Weight Management

Alcohol Consumption

Smoking Cessation

  • Advise and support all people who smoke to stop, in line with the recommendations on treating tobacco dependence in NICE's guideline on tobacco.

Plant Stanols and Sterols

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

Initial Lipid Measurement and Referral for Specialist Review

  • Measure both total blood cholesterol and high-density lipoprotein (HDL) cholesterol to achieve the best estimate of CVD risk.
  • Use clinical findings, a full 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. 
  • Use the recommendations in NICE's guidelines on familial hypercholesterolaemia to determine whether to suspect, and how to treat, familial hypercholesterolaemia.
  • Arrange for specialist assessment of people with a total blood cholesterol concentration over 9.0 mmol/litre or a non-HDL cholesterol concentration over 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 level 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 level remains at more than 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 over 7.5 mmol/litre. 

Discussions and Assessment Before Starting Statins

Discuss Risks and Benefits of Statins

  • Make decisions about starting statin treatment after an informed discussion between the clinician and the person about the risks and benefits of statins.
  • Take into account potential benefits from lifestyle changes, the person's preferences, the presence of any comorbidities, whether they are on multiple medications, whether they are frail and their life expectancy. (See also NICE's guideline on multimorbidity.)
  • Advise people who are being offered a statin that the risk of muscle pain, tenderness or weakness associated with statin use is small and the rate of severe muscle adverse effects (rhabdomyolysis) because of statins is extremely low.

Discuss Possible Interactions Between Statins and Other Substances

  • 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.

Perform Baseline Blood Tests and Clinical Assessment

  • Before starting statins perform baseline blood tests and clinical assessment. Include all of the following in the assessment:
  • Do not routinely exclude from statin treatment people who have liver transaminase levels that are raised but are less than 3 times the upper limit of normal.
  • Before offering a statin, ask the person if they have had persistent generalised unexplained muscle symptoms (pain, tenderness or weakness), whether associated or not with previous lipid-lowering treatment. 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 (see the section on when statins are contraindicated or not tolerated)
    • raised but less than 5 times the upper limit of normal, start statin treatment at a lower dose.

Choice of Drug Based on Clinical Trials

  • Be aware that when deciding on lipid-lowering treatment to prevent CVD, drugs are preferred for which there is evidence in clinical trials of a beneficial effect on CVD morbidity and mortality.

Statins and Pregnancy

  • Be aware that statins are contraindicated in pregnancy because of the risk to the unborn child of exposure to statins.
  • Explain that:
    • statins should be stopped if pregnancy is a possibility
    • statins should be stopped 3 months before attempting to conceive
    • statins should not be restarted until breastfeeding is finished.

Statins for Primary Prevention of Cardiovascular Disease

There is a NICE patient decision aid to support discussions about statin treatment to reduce the risk of heart disease and stroke for people without CVD.

Lipid Target for People Taking Statins

  • For primary prevention of CVD aim for a greater than 40% reduction in non-HDL cholesterol.

Optimising Lifestyle Changes

Treating Comorbidities and Secondary Causes of Dyslipidaemia

  • Before starting statins, treat comorbidities and secondary causes of dyslipidaemia.

People With and Without Type 2 Diabetes

  • Offer atorvastatin 20 mg for the primary prevention of CVD to people who have a 10‑year QRISK3 score of 10% or more.
  • Do not rule out treatment with atorvastatin 20 mg for the primary prevention of CVD just because the person's 10‑year QRISK3 score is less than 10% if they have an informed preference for taking a statin or there is concern that risk may be underestimated.
  • For people aged 85 and older consider treatment with atorvastatin 20 mg. Be aware of factors that may make treatment inappropriate (see the first two recommendations in the section Discussions and Assessment Before Starting Statins).

People 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.
  • Consider statin treatment for the primary prevention of CVD for people aged 18 to 40 with type 1 diabetes, including those who have had diabetes for 10 years or less.
  • When starting treatment with a statin for adults with type 1 diabetes, use atorvastatin 20 mg.
For recommendations on lipid-lowering treatment for secondary prevention of cardiovascular disease, refer to the secondary care summary.

Primary and Secondary Prevention for People with Chronic Kidney Disease

See NICE's guideline on chronic kidney disease for CKD classification. People on renal replacement therapy are outside the scope of this guideline.

  • Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
  • If the lipid target for primary or secondary prevention of CVD is not met and eGFR is 30 ml per minute per 1.73 m2 or more, increase the dose of atorvastatin.
  • Agree the use of higher doses with a renal specialist if eGFR is less than 30 ml/min/1.73 m2. 

Optimising Treatment for People on Statins

  • If the lipid target for primary or secondary prevention of CVD is not met:
    • discuss adherence and timing of statin dose with the person
    • encourage them to continue improvements to their diet and lifestyle, and to make further changes if appropriate
    • consider increasing the statin intensity/dose if the person is not currently taking a high-intensity statin at the maximum tolerated dose.
  • If the person reports adverse effects when taking a high-intensity statin discuss the following strategies with them:
    • stopping the statin and trying again when the symptoms have resolved to check if the symptoms are related to the statin 
    • changing to a different statin in the same intensity group (rosuvastatin if already receiving atorvastatin)
    • reducing the dose 
    • changing to a lower intensity statin. 
  • If a person is not able to tolerate a high-intensity statin aim to treat with the maximum tolerated intensity and dose of statin.
  • Advise the person that any statin at any dose reduces CVD risk.
For recommendations on contraindications and assessing response to treatment, refer to the secondary care summary.

Lipid-lowering Treatments that Should Not be Used or Not Used Routinely

These recommendations apply to primary and secondary prevention of CVD, including people with diabetes and CKD. 

They do not apply to people with FH. For guidance on using fibrates, bile acid sequestrants, and combination treatment for this population group, follow the recommendations on Drug Treatment in NICE’s guideline on familial hypercholesterolaemia.

  • Do not offer coenzyme Q10 or vitamin D to increase adherence to statin treatment
  • Do not routinely offer fibrates to prevent CVD
  • Do not offer nicotinic acid (niacin) to prevent CVD
  • Do not offer a bile acid sequestrant (anion exchange resin) to prevent CVD.

Omega 3 Fatty Acid Compounds

Combination Treatment 

References

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