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Lipid Modification for the Prevention of Cardiovascular Disease (CVD)

NICE Guideline

Patients 40 years and over

PRIMARY PREVENTION

Pre-existing CVD Other high-risk groups Perform clinical assessment,

NO ●●CKD (eGFR <60ml/min/1.73m2 and/or offer lifestyle advice and manage
NO
SECONDARY albuminuria) modifiable risk factors (see box 1)
YES ●●Type I diabetes (especially if >10-year
PREVENTION
history, established nephropathy or other CVD
risk factors)
Chronic kidney disease (CKD)
YES ●●Age ≥85 years
NO
Note: Familial lipid disorders - see NICE
Atorvastatin 80mg Clinical Guideline CG71 Estimate 10-year CVD risk using
●●Use lower dose if potential drug QRISK2 equation and clinical
interactions, high risk of adverse YES judgment
effects or patient prefers
●●Perform clinical assessment and
offer lifestyle advice (see box 1) Perform clinical assessment, offer lifestyle
●●Management of modifiable risk <10% risk
advice and manage modifiable risk factors ≥10% risk
factors should be performed but must (see box 1)
not delay statin treatment
Risk modifiers
●●Ethnicity
●●Family history of premature CVD
Follow-up of patients taking statins ●●Other considerations
Atorvastatin 20mg – socioeconomic status
Efficacy monitoring
●●Measure TC, HDL-C and non-HDL-C at 3 months ≥10% risk – BMI >40kg/m2
– If <40% reduction in non-HDL-C, check – type II diabetes
adherence, timing of dose, diet and lifestyle – serious mental health problems
measures and consider increasing dose if <80mg – treated with antihypertensives,
and patient at high risk (seek specialist advice if High-intensity statin not lipid-modifying drugs,
eGFR <30ml/min/1.73m2). tolerated (see box 2) antipsychotics, corticosteroids or
●●Review patients annually thereafter and consider immunosuppressants
measuring non-HDL-C to inform discussion ●●Reduce to maximum tolerated dose – recently stopped smoking
●●Consider switching patients taking a low- or ●●If adverse effects on high-intensity – treated for HIV
medium-intensity statin to a high-intensity statin statin: – systemic inflammatory
(see box 2) –– Interrupt treatment and restart to disorders
Safety monitoring check symptoms related to statin
●●Measure transaminases within 3 months and at 12 –– Reduce dose
–– Change to lower-intensity statin <10% risk
months (not again unless clinically indicated)
●●Advise patients to report muscle pain, tenderness (see box 2)
or weakness; measure creatine kinase if occurs ●●Seek specialist advice if patient in
●●Advise women to stop taking statin if pregnancy is a high-risk group and intolerant to 3 ●●Review risk on an ongoing basis
possibility or 3 months before attempting to conceive different statins ●●Reinforce lifestyle advice

BOX 1 BOX 2: CLASSIFICATION OF STATIN INTENSITY

Clinical Assessment
●● BP
●● BMI
●● HbA1c
●● Renal function and eGFR
●● Transaminases
●● TSH
●● Smoking status
●● Alcohol consumption
●● TC, non-HDL-C, HDL-C and TG
(if not already available)*
●●If unexplained muscle pain
before starting statin, check
creatine kinase levels
Lifestyle Advice High intensity Low intensity
●● Diet and weight (>40% reduction in LDL-C): (20–30% reduction in LDL-C):
●● Physical activity Atorvastatin ≥20mg Fluvastatin 20–40mg
●● Alcohol reduction Simvastatin 80mg† Pravastatin
●● Smoking cessation Rosuvastatin ≥10mg Simvastatin 10mg
*Refer if TC >9mmol/L, non- Medium intensity †Increased risk of myopathy:
HDL-C >7.5mmol/L or TG (31–40% reduction in LDL-C): consider only if severe
persistently >10mmol/L (urgently Atorvastatin 10mg hypercholesterolaemia with
if TG >20mmol/L and not due to Fluvastatin 80mg high risk of cardiovascular
excess alcohol or poor glycaemic Simvastatin 20–40mg complications when treatment
control) Rosuvastatin 5mg goals not achieved on lower
doses and benefits outweigh
risks.

KEY: Non-HDL-C = TC – HDL-C

Adapted from NICE Clinical Guideline 181 (July 2014; updated July 2016): Lipid modification: cardiovascular risk assessment and the modification of
blood lipids for the primary and secondary prevention of cardiovascular disease. The full guideline is available at www.nice.org.uk/CG181.