MIMS Summary: NICE lipid modification guidance

New guidance from NICE on the primary and secondary prevention of cardiovascular disease focuses on the modification of blood lipids.

The new guidance encourages GPs to identify patients likely to be at high risk of CVD using the Framingham data.

Unlike the JBS2 guidance on the prevention of CVD, which recommends use of the JBS prediction charts to assess CVD risk and focuses on both BP and lipid levels, the NICE guidance concentrates solely on the reduction of blood cholesterol as a key modifiable risk factor in people with established CVD and those at high risk of CVD.

In line with this, the guidance provides specific advice on choice and dose of statins.

KEY PRIORITIES FOR IMPLEMENTATION

Primary prevention

  • Identify people aged 40–74 years likely to be at high risk of CVD using a systematic strategy rather than opportunistic assessment.
  • Prioritise people on the basis of their estimated CVD risk before a full formal risk assessment (use CVD risk factors already recorded in primary care electronic medical records — age, sex, mean systolic BP, TC, HDL-C, smoking status, left ventricular hypertrophy).
  • Estimate CVD risk using the Framingham 1991 10-year risk equations.

Framingham risk:

CVD risk = 10-year risk of fatal and non-fatal stroke, including transient ischaemic attack + 10-year risk of coronary heart disease (CHD)*(Calculate CHD risk online)

*CHD risk includes risks of death from CHD and nonfatal CHD, including silent MI, angina and acute coronary syndrome.

  • Offer patients detailed information about their absolute CVD risk and about the risks and benefits of an intervention over a 10-year period.
  • Before offering lipid modification therapy optimise management of other modifiable CVD risk factors if possible. Treat comorbidities and secondary causes of dyslipidaemia. See Box 1 for assessment schedule.
  • Offer statin therapy to people with 10-year CVD risk ≥20% (see Box 2). Use clinical assessment to estimate risk when a risk calculator is not appropriate, e.g. patients with diabetes or those in high-risk ethnic groups.

Secondary prevention

  • Offer lipid modification therapy as soon as possible, do not delay by management of modifiable risk factors.
  • Conduct blood tests and clinical assessment as for primary prevention (see Box 1). Treat comorbidities and secondary causes of dyslipidaemia.
  • Offer statin therapy to all adults with clinical evidence of CVD (see Box 2).

Box 1: CVD assessment

Assessment for CVD should include the following:

  • Smoking status
  • Alcohol consumption
  • BP
  • BMI or other measure of obesity
  • Fasting TC, LDL-C, HDL-C and triglycerides (if not already available)
  • Fasting blood glucose
  • Renal function
  • Liver function (transaminases)
  • Thyroid stimulating hormone (TSH) if dyslipidaemia is present

Box 2:  Recommended treatment


Primary prevention:

  • Offer simvastatin 40mg* (or drug of similar efficacy and cost) for adults >40 years with 10-year CVD risk ≥20%.


Secondary prevention:

  • Offer simvastatin 40mg* (or drug of similar efficacy and cost) to all adults with clinical evidence of CVD.
  • Consider increasing simvastatin dose to 80mg or drug of similar efficacy and cost if TC and LDL-C targets not reached.
  • Offer higher intensity statin (e.g. simvastatin 80mg) to people with acute coronary syndrome. Do not delay until lipid levels available; measure fasting lipid levels after approx. 3 months.

*If potential drug interactions or simvastatin 40mg contraindicated, offer lower dose of simvastatin or pravastatin.


Treatment targets


Primary prevention:

  • No target level for TC or LDL-C


Secondary prevention:

  • TC <4mmol/L (audit level <5mmol/L)
  • LDL-C <2mmol/L

 

The full guideline is available on the NICE website

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