Cardiovascular disease (CVD) accounts for up to one-third of deaths in England and Wales, with the majority related to IHD.
There is some evidence to suggest that although CVD mortality is decreasing, morbidity is increasing.
Non-modifiable CVD risk factors include age, sex, ethnicity and family history. Modifiable risk factors include smoking, hypertension and raised cholesterol levels.
Current NICE guidance advises using non-HDL cholesterol, rather than LDL cholesterol levels.1 Non-HDL cholesterol is total cholesterol minus HDL cholesterol.
Measurement of LDL cholesterol requires a fasting sample and triglyceride levels <4.5mmol/L, non-HDL cholesterol does not.
NICE recommends formal assessment of patients if their estimated 10-year risk of CVD is 10% or more.
The QRISK2 risk assessment tool may be used to identify patients under 85 years of age who might benefit from primary prevention of CVD. Patients over the age of 40 years may have their CVD risk status reviewed, but NICE does not state the frequency at which this should take place.
QRISK2 may be used, but clinical judgment should also be employed. For example, a decision on primary prevention of CVD may be made in the context of a family history of premature CVD.
This tool may be used in type 2 diabetes, but not type 1. It should not be used if the eGFR is less than 60 and/or there is albuminuria in the context of familial hyper-cholesterolaemia those with existing CVD.
There is an increased CVD risk in patients being treated for HIV, those taking antipsychotics, which may cause dyslipidaemia, and those taking steroid therapy. It is important to exclude other causes of dyslipidaemia, such as excessive alcohol and uncontrolled diabetes.
For primary prevention, atorvastatin 20mg may be initiated in those with a 10% or greater 10-year risk of CVD, in conjunction with management of modifiable CVD risk factors. In those aged 85 and over, a statin may be considered because it may reduce the risk of non-fatal MI.
NICE advises considering statin therapy for adults with type 1 diabetes who are over the age of 40, who have had diabetes for more than 10 years, or those with nephropathy or other CVD risk factors.
Atorvastatin 20mg may be used for primary prevention of CVD in patients with type 2 diabetes who have >10% risk of developing CVD, and in patients who have chronic kidney disease.
In patients with established CVD, atorvastatin 80mg may be given. The dosage should take account of possible side-effects and drug interactions, and patient choice.
In patients who do not wish to start statin therapy, it may still be helpful to reassess risk in the future. NICE advocates yearly medication reviews for patients taking statins.
If total cholesterol is >7.5mmol/L and there is a family history of premature heart disease, consider familial hypercholesterolaemia .
NICE recommends specialist referral in those with total cholesterol >9.0mmol/L or non-HDL cholesterol >7.5mmol/L, regardless of family history. Specialist referral is indicated in patients with a triglyceride concentration >20mmol/L. If the level is 10-20mmol/L, the measurement may be repeated within two weeks.
NICE advises that if the level is >10mmol/L, specialist referral is advisable. For triglyceride levels of 4.5-9.9mmol/L, CVD risk may be underestimated by risk assessment tools. Specialist advice is recommended if non-HDL cholesterol is >7.5mmol/L.
NICE lifestyle advice
Total fat intake should be 30% or less of total energy intake, saturated fats, 7% or less, and dietary cholesterol less than 300mg per day. If possible saturated fats should be replaced by mono- and polyunsaturated fats.
Patients should try to eat at least five portions of fruit and vegetables per day, at least two portions of fish per week, including one of oily fish, and at least four or five portions of unsalted nuts, seeds and legumes per week. They should aim for at least 150 minutes of moderate, or 75 minutes of vigorous, aerobic activity, or a mix of both, a week.
- NICE. Cardiovascular disease: risk assessment and reduction, including lipid modification. CG181. London, NICE, August 2015