New NICE Guidance On Lowering Cholesterol For People At High Risk Of Cardiovascular Disease

Main Category: Cardiovascular / Cardiology
Also Included In: Statins;  Cholesterol
Article Date: 28 May 2008 - 7:00 PDT

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The National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Primary Care (NCC PC) have today (28 May) issued new guidance to the NHS in England and Wales on the identification of people at risk of cardiovascular disease (CVD) and on the use of lipid lowering drugs to reduce that risk.

CVD - which includes heart disease and stroke - remains a leading cause of ill health and death in the United Kingdom. In 2005, CVD accounted for 124,000 deaths - or one in three of all deaths. Apart from age and sex, three modifiable risk factors - smoking, raised blood pressure and raised cholesterol - make a major contribution to CVD risk, particularly when they are combined. The risk of CVD can be calculated from these risk factors and people at highest risk can be identified. Blood cholesterol is a key modifiable risk factor and can be reduced by dietary change, physical activity and drugs. The NICE guideline addresses the identification of those at high risk (primary prevention), and the modification of lipids in these people and in people with established CVD (secondary prevention).

Important recommendations in the guideline include:

For the primary prevention of CVD

• For the primary prevention of CVD in primary care, a systematic strategy should be used to identify people aged 40-75 who are likely to be at high risk
• People should be prioritised on the basis of an estimate of their CVD risk before a full formal risk assessment. Their CVD risk should be estimated using CVD risk factors already recorded in primary care electronic medical records
• A modified Framingham 1991 10-year risk equations should be used to assess CVD risk
• Before offering drugs to reduce cholesterol levels, all other modifiable risk factors should be considered and their management optimised if possible
• Statin therapy is recommended as part of the management strategy for the primary prevention of CVD for adults who have a 20% or greater 10-year risk of developing CVD. Treatment should be initiated with simvastatin 40mg. If there are potential drug interactions, or simvastatin 40mg is contraindicated, a lower dose or alternative preparation such as pravastatin may be chosen.

For the secondary prevention of CVD

• Drugs to reduce cholesterol levels should be offered and should not be delayed by management of modifiable risk factors
• Statin therapy is recommended for adults with clinical evidence of CVD

Dr Gillian Leng, NICE Deputy Chief Executive, said: "This guideline will provide much needed clarity for healthcare professionals, many of whom report uncertainty in how to manage blood lipids in patients both with and without pre-existing cardiovascular disease. As a result, the guideline should also help to reduce the current variation in prescribing lipid modifying drugs in primary care. The guideline recommends treatment based on overall cardiovascular risk rather than on isolated lipid levels.

Dr John Robson, General Practitioner and Chair of the Guideline Development Group, said: "This guideline will be welcomed by patients and professionals as easy to adopt, well evidenced and efficient. It provides clear advice on the management and treatment of lipids in people who already have CVD or for people who are at high risk of developing it. Systematic review of CVD risk could involve more than 3 million people in assessment and treatment decisions with the potential to prevent around 15,000 heart attacks and strokes every year. This is a major public health initiative and will be a welcome addition to the Governments vascular programme as it ensures an efficient and equitable method of targeting treatment to those most likely to benefit. The recommended Framingham score for estimating risk includes new adjustments for ethnicity and family history. However, the GDG also recognised the potential for further improvement in risk estimation and recommends early review when new research is forthcoming."

Dr Tom Marshall, Public Health Specialist and member of the Guideline Development Group, said: "Cardiovascular disease is the leading cause of death in England and Wales accounting for 124,000 deaths (or one in three deaths) in 2005. For every one fatality, there are at least two people who have a major non-fatal CVD event. The guideline suggests an achievable and realistic strategy for identifying those people at high risk, giving them lifestyle advice and offering them treatment, and therefore can be expected to have an impact on the healthcare received by a significant proportion of the population."

Dr Norma O'Flynn, Clinical Director of the National Collaborating Centre for Primary Care, said: "The biggest change in clinical practice is likely to result from the guideline's recommendation that a systematic approach to the identification of patients at high risk of developing cardiovascular disease should be used in primary care. We are in quite a privileged position in the UK in that there is almost universal registration of the population in general practice, general practice has extremely high levels of computerisation and general practice records can be used to identify patients most likely to be at high risk. We can essentially find which of our patients are most likely to benefit from interventions to reduce risk. Our approach need no longer be primarily opportunistic."

Maureen Hogg, CHD Lead Nurse and member of the Guideline Development Group, said: "As a health professional I welcome this evidence-based guideline. It provides clear advice to all health professionals involved in the care and treatment of those people who are at increased risk of cardiovascular disease. Through the systematic identification of those at highest risk and those with established risk, patients and health professionals may engage in discussion and negotiation around lifestyle and pharmacological interventions. The guideline places patients centrally in any decision making about their management and emphasises the need to address all CVD risk factors in combination."

The guideline, together with a version for patients, is available from the NICE website at www.nice.org.uk/CG067