Cardiovascular Disease: Risk Assessment and Reduction, Including Lipid Modification in Secondary Care

Overview

This specialist Guidelines summary covers lipid modification therapy for the secondary prevention of cardiovascular disease (CVD). 

This guideline does not cover recommendations for people with familial hypercholesterolaemia (FH). For guidance on FH, see NICE’s guideline on familial hypercholesterolaemia: identification and management.

This summary is intended for use by cardiologists working in a secondary care setting. 

Please refer to the full guideline for the complete set of recommendations, including identifying and assessing cardiovascular disease risk for people without established cardiovascular disease, aspirin for primary prevention of cardiovascular disease, and lifestyle changes for the primary and secondary prevention of cardiovascular disease. For a summary of the recommendations relevant to primary care settings, see the separate Guidelines primary care summary.  

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

For recommendations on initial lipid measurement and referral for specialist review, please see the separate Guidelines primary care summary.  

Statins for Preventing Cardiovascular Disease

There is a NICE patient decision aid to support discussions about statin therapy to reduce the risk of heart disease and stroke.

• 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 the Guidelines primary care summary 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 the Guidelines primary care summary on obesity: identification, assessment and management)
  • total cholesterol, non‑high-density lipoprotein (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 underactive or overactive thyroid.

For recommendations on primary prevention, including prevention in patients with and without type 2 diabetes and patients with type 1 diabetes, see the separate Guidelines primary care summary.  

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 symptoms (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 its 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) 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 glycated haemoglobin (HbA1c). (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. 

Adherence to Statin Therapy

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

For recommendations on preventing cardiovascular disease with fibrates, nicotinic acid, bile acid sequestrants, and omega 3 fatty acid compounds, see the separate Guidelines primary care summary. 

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, see the Guidelines summary on familial hypercholesterolemia: identification and management.

Other Treatment Options

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