For the first time, as regards to appropriate lipid management in primary care, I am going to congratulate NICE on both counts: the lowering of the 10-year cardiovascular disease risk [threshold] to 10% from 20%, and the recognition that simvastatin must be left aside in favour of the more effective atorvastatin, which exhibits a much better side-effect profile than simvastatin.
The dose of atorvastatin 20mg is a good choice, but I would be starting with 10mg because 75% of the benefit of any statin is achieved with the lowest licensed dose of a statin. In the case of atorvastatin 10mg, the side effects, such as myalgia, are much rarer and far better tolerated.
The JUPITER study did show that in primary prevention, the cardiovascular benefit of the statin used (rosuvastatin 20mg) was evident above and below 10% 10-year cardiovascular disease risk.
In my view, NICE should indicate ≥10% 10-year cardiovascular disease risk, but also leave it to the discretion of the clinicians to prescribe atorvastatin 10mg for some specific patients with <10% risk.
NICE is now getting on the right track as regards to lipid management. One can ask why did it take NICE so long to see the obvious in lipids, but this debate can be left for another day.