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