Cardiovascular Disease: Risk Assessment and Reduction, Including Lipid Modification

Overview

This updated Guidelines summary covers the assessment and care of adults who are at risk of, or who have, cardiovascular disease (CVD), such as heart disease or stroke. It aims to help healthcare professionals to identify people who are at risk of cardiovascular problems, including people with type 1 or type 2 diabetes, or chronic kidney disease. It describes the lifestyle changes people can make and how statins can be used to reduce their risk.

This summary only includes recommendations for primary care. For a complete set of recommendations, refer to the full guideline.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Identifying and Assessing Cardiovascular Disease Risk for People Without Established Cardiovascular Disease

Identifying People for Full Formal Risk Assessment

• For the primary prevention of cardiovascular disease (CVD) in primary care, use a systematic strategy to identify people who are likely to be at high risk of CVD. 
• Prioritise people on the basis of an estimate of their CVD risk before doing a full formal risk assessment. Estimate their CVD risk using CVD risk factors already recorded in primary care electronic medical records. 
• Review estimates of CVD risk on an ongoing basis for people over 40.
• Prioritise people for a full formal risk assessment if their estimated 10-year risk of CVD is 10% or more. 
• Discuss the process of risk assessment with the person identified as being at risk, including the option of declining any formal risk assessment. 
• Do not use opportunistic assessment as the main strategy in primary care to identify CVD risk in unselected people. 

Full Formal Risk Assessment

• Use the QRISK3 tool to calculate the estimated CVD risk within the next 10 years for people aged between 25 and 84 without CVD.
• Use the QRISK3 tool for people with type 2 diabetes aged between 25 and 84.

  Until electronic clinical systems in which QRISK2 is embedded are updated with QRISK3, it may be necessary to use QRISK2. When assessing risk for people taking corticosteroids or atypical antipsychotics or people with systemic lupus erythematosus, migraine, severe mental illness or erectile dysfunction, use QRISK3 (the online version of QRISK3, if necessary) because QRISK2 does not take these risk factors into account and so may underestimate the 10‑year CVD risk in these populations.

• Do not use a risk assessment tool for people who are at high risk of CVD, including people with:
  • type 1 diabetes (see the section on primary prevention of CVD for people with type 1 diabetes)
  • an estimated glomerular filtration rate less than 60 ml/min/1.73 m² and/or albuminuria (see the section on primary and secondary prevention of CVD for people with chronic kidney disease)
  • familial hypercholesterolaemia (see NICE's guideline on familial hypercholesterolaemia) or other inherited disorders of lipid metabolism.
• Recognise that CVD risk tools may underestimate risk in certain groups of people, including but not limited to:
  • people treated for HIV
  • people already taking medicines to treat CVD risk factors
  • people who have recently stopped smoking
  • people taking medicines that can cause dyslipidaemia such as immunosuppressant drugs
  • people with severe mental illness
  • people with autoimmune disorders, and other systemic inflammatory disorders.
• Consider people aged 85 or older to be at increased risk of CVD because of age alone, particularly people who smoke or have raised blood pressure.

Communication about Risk Assessment, Lifestyle Changes, and Treatment

• Follow the recommendations on communication in NICE's guidelines on patient experience in adult NHS services and shared decision making.
• Set aside adequate time during the consultation to provide information on risk assessment and to answer any questions. Arrange for further consultation if needed.
• Document the discussion relating to the consultation on risk assessment and the person's decision. 
• Offer people information about their absolute risk of CVD and about the absolute benefits and harms of an intervention over a 10-year period.
• Consider using a lifetime risk tool such as QRISK3-lifetime to inform discussions on CVD risk and to motivate lifestyle changes, particularly for people with a 10‑year QRISK3 score less than 10%, and people under 40 who have CVD risk factors.
• To encourage the person to participate in reducing their CVD risk:
  • find out what, if anything, the person has already been told about their CVD risk and how they feel about it
  • explore the person's beliefs about what determines future health (this may affect their attitude to changing risk)
  • assess their readiness to make changes to their lifestyle (diet, physical activity, smoking and alcohol consumption), to undergo investigations and to take long-term medication
  • assess their confidence to make changes to their lifestyle, undergo investigations and take medication
  • inform them of potential future management options based on current evidence and best practice
  • involve them in developing a shared management plan
  • check that they have understood what has been discussed. 
• If the person's CVD risk is at a level where intervention is recommended but they decline the offer of treatment, advise them that their CVD risk should be reassessed again in the future. Record their choice in their medical records. 

Aspirin for Primary Prevention of Cardiovascular Disease

• Do not routinely offer aspirin for primary prevention of CVD.

Lifestyle Changes for the Primary and Secondary Prevention of Cardiovascular Disease

Behaviour Change

• Advise and support people at high risk of or with CVD to achieve a healthy lifestyle in line with NICE's guideline on behaviour change: general approaches.

Healthy Eating 

For advice on healthy eating, see the NHS eat well guide.

Cardioprotective Diet

• Advise people at high risk of or with CVD to eat a diet in which total fat intake is 30% or less of total energy intake, saturated fats are 7% or less of total energy intake, and where possible saturated fats are replaced by mono-unsaturated and polyunsaturated fats. 
• Advise people at high risk of or with CVD to:
  • reduce their saturated fat intake
  • increase their mono-unsaturated fat intake with olive oil, rapeseed oil or spreads based on these oils and to use them in food preparation. 
• Take account of a person's individual circumstances—for example, drug therapy, comorbidities and other lifestyle modifications when giving dietary advice. 

Physical Activity

• Advise people at high risk of or with CVD to do aerobic and muscle-strengthening activities in line with the UK Chief Medical Officers' physical activity guidelines.
• Encourage people who are unable to perform moderate intensity physical activity because of comorbidity, medical conditions or personal circumstances to exercise at their maximum safe capacity. 
• Advice about physical activity should take into account the person's needs, preferences and circumstances. Agree goals and provide the person with written information about the benefits of activity and local opportunities to be active, in line with recommendation 2 of NICE's guideline on physical activity: brief advice for adults.
• Follow recommendation 8 of NICE's guideline on walking and cycling, and recommendation 2 of NICE's guideline on exercise referral schemes.

Weight Management

• Offer people at high risk of or with CVD who are overweight or obese appropriate interventions, in line with NICE's guideline on obesity: identification, assessment and management. 

Alcohol Consumption

• For advice on how to keep the health risks from drinking alcohol to a low level, see the UK Chief Medical Officer's alcohol consumption guidelines.

Smoking Cessation

• Advise and support all people who smoke to stop, in line with the recommendations on treating tobacco dependence in NICE's guideline on tobacco.

Plant Stanols and Sterols

• Do not advise any of the following to take plant stanols or sterols to prevent CVD:
  • people being treated for primary prevention
  • people being treated for secondary prevention
  • people with CKD
  • people with type 1 diabetes
  • people with type 2 diabetes. 

Lipid Modification Therapy for the Primary and Secondary Prevention of Cardiovascular Disease

• Be aware that when deciding on lipid modification therapy to prevent CVD, drugs are preferred for which there is evidence in clinical trials of a beneficial effect on CVD morbidity and mortality. 

Initial Lipid Measurement and Referral for Specialist Review

• Measure both total blood cholesterol and high-density lipoprotein (HDL) cholesterol to achieve the best estimate of CVD risk. 
• Before starting lipid modification therapy for the primary prevention of CVD, take at least 1 blood sample to provide a full lipid profile. Measure total cholesterol, HDL cholesterol, non-HDL cholesterol and triglyceride concentrations. A fasting sample is not needed.
• Use the clinical findings, lipid profile and family history to judge the likelihood of a familial lipid disorder, rather than the use of strict lipid cut off values alone. 
• Exclude possible common secondary causes of dyslipidaemia (such as excess alcohol, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome) before referring for specialist review. 
• Use the recommendations in NICE's guidelines on familial hypercholesterolaemia to determine whether to suspect, and how to treat, familial hypercholesterolaemia.
• Arrange for specialist assessment of people with a total blood cholesterol concentration over 9.0 mmol/litre or a non-HDL cholesterol concentration over 7.5 mmol/litre even in the absence of a first-degree family history of premature coronary heart disease. 
• Refer for urgent specialist review if a person has a triglyceride concentration over 20 mmol/litre that is not a result of excess alcohol or poor glycaemic control. 
• In people with a triglyceride concentration between 10 and 20 mmol/litre:
  • repeat the triglyceride measurement with a fasting test (after an interval of 5 days, but within 2 weeks) and
  • review for potential secondary causes of hyperlipidaemia and
  • seek specialist advice if the triglyceride concentration remains over 10 mmol/litre. 
• In people with a triglyceride concentration between 4.5 and 9.9 mmol/litre:
  • be aware that the CVD risk may be underestimated by risk assessment tools and
  • optimise the management of other CVD risk factors present and
  • seek specialist advice if non-HDL cholesterol concentration is over 7.5 mmol/litre. 

Statins for Preventing Cardiovascular Disease

• Decide whether to start statin therapy after an informed discussion between the clinician and the person about the risks and benefits of statin treatment, taking into account additional factors such as potential benefits from lifestyle changes, informed patient preference, comorbidities, polypharmacy, general frailty and life expectancy. (See also NICE's guideline on multimorbidity.)
• Before starting statin treatment perform baseline blood tests and clinical assessment, and treat comorbidities and secondary causes of dyslipidaemia. Include all of the following in the assessment:
  • smoking status
  • alcohol consumption
  • blood pressure (see NICE's guideline on hypertension)
  • BMI or other measure of obesity (see NICE's guideline on obesity: identification, assessment and management)
  • total cholesterol, non-HDL cholesterol, HDL cholesterol and triglycerides
  • diabetes status
  • renal function
  • transaminase level (alanine aminotransferase or aspartate aminotransferase)
  • thyroid-stimulating hormone in people with symptoms of overactive or underactive thyroid. 

Primary Prevention

• Before offering statin treatment for primary prevention, discuss the benefits of lifestyle changes and optimise the management of all other modifiable CVD risk factors if possible. 
• Recognise that people may need support to change their lifestyle. To help them do this, refer them to programmes such as exercise referral schemes or weight management services. (See NICE's guidelines on behaviour change: individual approaches, physical activity: exercise referral schemes and weight management: lifestyle services for overweight or obese adults). 
• Offer people the opportunity to have their risk of CVD assessed again after they have tried to change their lifestyle. 
• If lifestyle change is ineffective or inappropriate offer statin treatment.

Primary Prevention for People With and Without Type 2 Diabetes

• Offer atorvastatin 20 mg for the primary prevention of CVD to people who have a 10-year QRISK3 score of 10% or more. 
• Do not rule out treatment with atorvastatin 20 mg for the primary prevention of CVD just because the person's 10‑year QRISK3 score is less than 10% if they have an informed preference for taking a statin or there is concern that risk may be underestimated.
• For people aged 85 and older consider treatment with atorvastatin 20 mg. Be aware of factors that may make treatment inappropriate (see the first recommendation in the section, Statins for Preventing Cardiovascular Disease).

  See also the section on follow-up of people started on statin treatment.

Primary Prevention for People With Type 1 Diabetes 

• Consider statin treatment for primary prevention of CVD for adults with type 1 diabetes. 
• Offer statin treatment for the primary prevention of CVD to adults with type 1 diabetes who: 
  • are older than 40 years or 
  • have had diabetes for more than 10 years or 
  • have established nephropathy or 
  • have other CVD risk factors. 
• When starting treatment with a statin for adults with type 1 diabetes, use atorvastatin 20 mg. 
  
  See also the section on follow-up of people started on statin treatment. 

Secondary Prevention for People With and Without Type 1 or 2 Diabetes

• Start statin treatment in people with CVD with atorvastatin 80 mg. Use a lower dose of atorvastatin if any of the following apply:
  • potential drug interactions
  • high risk of adverse effects
  • patient preference.

    In May 2023, this was an off-label use of atorvastatin. See NICE's information on prescribing medicines.

• Do not delay statin treatment for secondary prevention of CVD but consider lifestyle changes at the same time if appropriate. 
• If a person has acute coronary syndrome do not delay statin treatment. Take a lipid sample on admission and about 3 months after the start of treatment. 
  
  See also the section on follow-up of people started on statin treatment.

Primary and Secondary Prevention for People with Chronic Kidney Disease

• Offer atorvastatin 20 mg for the primary or secondary prevention of CVD to people with CKD.
• Increase the dose if a greater than 40% reduction in non-HDL cholesterol is not achieved (see the following recommendation) and eGFR is 30 ml/min/1.73 m² or more.
• Agree the use of higher doses with a renal specialist if eGFR is less than 30 ml/min/1.73 m². 
  
  See also the section on follow-up of people started on statin treatment.
  
  See NICE's guideline on chronic kidney disease for CKD classification. People on renal replacement therapy are outside the scope of this guideline. 

Follow-up of People Started on Statin Treatment

• Measure total cholesterol, HDL cholesterol and non-HDL cholesterol in all people who have been started on high-intensity statin treatment (both primary and secondary prevention, including atorvastatin 20 mg for primary prevention) at 3 months of treatment. 
• Aim for a greater than 40% reduction in non-HDL cholesterol. 
• If a greater than 40% reduction in non-HDL cholesterol is not achieved:
  • discuss adherence and timing of dose
  • optimise adherence to diet and lifestyle measures
  • consider increasing the dose if started on less than atorvastatin 80 mg and the person is judged to be at higher risk because of comorbidities, risk score or using clinical judgement. 
• Provide annual medication reviews for people taking statins.
  • Use these reviews to discuss medicines adherence and lifestyle changes and address CVD risk factors.
  • Consider an annual non-fasting blood test for non-HDL cholesterol to inform the discussion. 
• Discuss with people who are stable on a low- or medium-intensity statin the likely benefits and potential risks of changing to a high-intensity statin when they have a medication review and agree with the person whether a change is needed. 

Advice and Monitoring for Adverse Effects

• Advise people who are being treated with a statin:
  • that other drugs, some foods (for example, grapefruit juice) and some supplements may interfere with statins and
  • to always consult the patient information leaflet, a pharmacist or prescriber for advice when starting other drugs or thinking about taking supplements. 
• Remind the person to restart the statin if they stopped taking it because of drug interactions or to treat intercurrent illnesses.
• Before offering a statin, ask the person if they have had persistent generalised unexplained muscle pain (pain, tenderness or weakness), whether associated or not with previous lipid-lowering therapy. If they have, measure creatine kinase levels. If creatine kinase levels are:
  • more than 5 times the upper limit of normal, re-measure creatine kinase after 7 days; if creatine kinase levels are still 5 times the upper limit of normal, do not start statin treatment (see the section on intolerance of statins, and for other treatment options, see the NICE technology appraisal guidance on our topic page on lipid disorders)
  • raised but less than 5 times the upper limit of normal, start statin treatment at a lower dose. 
• Advise people who are being offered a statin that the risk of muscle pain, tenderness or weakness associated with statin use is small and the rate of severe muscle adverse effects (rhabdomyolysis) because of statins is extremely low.
• Advise people who are being treated with a statin to seek medical advice if they develop unexplained muscle symptoms (pain, tenderness or weakness). If this occurs, measure creatine kinase. 
• If people report muscle pain, tenderness or weakness while taking a statin, and have a creatine kinase level less than 5 times the upper limit of normal, reassure them that their symptoms are unlikely to be due to the statin and explore other possible causes. 
• Do not measure creatine kinase levels in asymptomatic people who are being treated with a statin. 
• Measure liver transaminase within 3 months of starting treatment (as well as at baseline, see the second recommendation in the section, Statins for Preventing Cardiovascular Disease) and at 12 months, but not again unless clinically indicated. 
• Do not routinely exclude from statin therapy people who have liver transaminase levels that are raised but are less than 3 times the upper limit of normal. 
• Do not stop statins because of an increase in blood glucose level or HbA_1c.  (See the recommendations on assessing for risk of diabetes mellitus in NICE's guideline on preventing type 2 diabetes.)
• Be aware that statins are contraindicated in pregnancy because of the risk to the unborn child of exposure to statins.
• Explain that:
  • statins should be stopped if pregnancy is a possibility
  • statins should be stopped 3 months before attempting to conceive
  • statins should not be restarted until breastfeeding is finished. 

Intolerance of Statins

• If a person is not able to tolerate a high-intensity statin aim to treat with the maximum tolerated dose.
• Tell the person that any statin at any dose reduces CVD risk. If someone reports adverse effects when taking a high-intensity statin discuss the following possible strategies with them:
  • stopping the statin and trying again when the symptoms have resolved to check if the symptoms are related to the statin
  • changing to a different statin in the same intensity group (rosuvastatin if already receiving atorvastatin)
  • reducing the dose within the same intensity group
  • changing the statin to a lower intensity group.
• Seek specialist advice about options for treating people at high risk of CVD such as those with CKD, type 1 diabetes, type 2 diabetes or genetic dyslipidaemias, and those with CVD who are intolerant to 3 different statins. Seek advice by telephone, virtual clinic or referral.

Adherence to Statin Therapy

• Do not offer coenzyme Q10 or vitamin D to increase adherence to statin treatment.

Fibrates for Preventing Cardiovascular Disease

• Do not routinely offer fibrates to prevent CVD to any of the following:
  • people who are being treated for primary prevention
  • people who are being treated for secondary prevention
  • people with CKD
  • people with type 1 diabetes
  • people with type 2 diabetes.
    
    For people with familial hypercholesterolaemia, follow the recommendations on drug treatment in NICE's guideline on familial hypercholesterolaemia.

Nicotinic Acid for Preventing Cardiovascular Disease

• Do not offer nicotinic acid (niacin) to prevent CVD to any of the following:
  • people who are being treated for primary prevention
  • people who are being treated for secondary prevention
  • people with CKD
  • people with type 1 diabetes
  • people with type 2 diabetes.

Bile Acid Sequestrants (Anion Exchange Resins) for Preventing Cardiovascular Disease

• Do not offer a bile acid sequestrant (anion exchange resin) to prevent CVD to any of the following:
  • people who are being treated for primary prevention
  • people who are being treated for secondary prevention
  • people with CKD
  • people with type 1 diabetes
  • people with type 2 diabetes.
    
    For people with familial hypercholesterolaemia, follow the recommendations on drug treatment in NICE's guideline on familial hypercholesterolaemia.

Omega 3 Fatty Acid Compounds for Preventing Cardiovascular Disease

• Do not offer omega 3 fatty acid compounds to prevent CVD to any of the following:
  • people who are being treated for primary prevention
  • people who are being treated for secondary prevention
  • people with CKD
  • people with type 1 diabetes
  • people with type 2 diabetes.
    
    Icosapent ethyl is an exception to this if used as described in NICE's technology appraisal guidance on icosapent ethyl with statin therapy for reducing the risk of cardiovascular events in people with raised triglycerides.
• Tell people that there is no evidence that omega 3 fatty acid compounds help to prevent CVD, except use of icosapent ethyl as described in NICE's technology appraisal guidance on icosapent ethyl with statin therapy.

Combination Therapy for Preventing Cardiovascular Disease

• To prevent CVD, do not offer the combination of a statin with:
  • a bile acid sequestrant (anion exchange resin), a fibrate or nicotinic acid, or
  • an omega 3 fatty acid compound, except icosapent ethyl as described in NICE's technology appraisal guidance on icosapent ethyl with statin therapy.
    
    For people with familial hypercholesterolaemia, follow the recommendations on drug treatment in NICE's guideline on familial hypercholesterolaemia.

Other Treatment Options

• For other treatment options, see the NICE technology appraisal guidance on its topic page on lipid disorders.