This comes from NICE guideline CG181.
- Lipid checks for primary prevention can now be non-fasting (even for triglycerides), which is going to make life somewhat simpler.
- Rather than LDL, we should now be focusing on non-HDL, which apparently is simpler and more cost-effective.
- The cut-off for primary prevention is now 10% 10-year risk with QRISK2.
- QRISK2 can be used up to age 84 years. I’m not sure what we do in older patients.
- For primary prevention, first choice is Atorvastatin 20 mg od.
- For people with established CVD, NICE recommends Atorvastatin 80 mg in the absence of potential drug interactions/high risk of adverse effects, but the problem is that it isn’t officially licenced and so we have to explain this. I need to look up their evidence.
- In patients on high-intensity statin treatment (which I guess means people with existing CVD? not clear), measure total cholesterol/HDL/non-HDL at three months and aim for >40% reduction in non-HDL. If this isn’t managed, look at adherence, timing, diet, & lifestyle, and consider increasing dose up to 80mg if not already done.
- Remember to give them lifestyle advice.
- There is no evidence that stanols or sterols are helpful in reducing risk of CVD, either for primary or secondary prevention. There’s no evidence that they don’t work, either, but NICE’s (sensible) position is that in the absence of evidence we shouldn’t be advising people to spend the extra money. There doesn’t seem to be any evidence of harm, either, so if the subject comes up we can assumedly make it clear that it’s a ‘pig in a poke’ situation.
In people with eGFR<60, don’t calculate QRISK2 – just start them on Atorvastatin 20 mg, and increase it if needed to get >40% reduction in non-HDL cholesterol. Unless their eGFR is <30, in which case the decision about higher doses should be made by their renal team.
We do now use QRISK2 for patients with Type 2 DM. Not for Type 1, however; they should be treated if >40 years old, >10 years since diagnosis, or other risk factors such as nephropathy. Initial treatment, again, is 20 mg Atorvastatin; the guideline doesn’t say whether we’re meant to treat to target.
FHL/other inherited disorders of lipid metabolism
Don’t use QRISK2. Guidelines for FHL are at CG71. Consider FHC if total cholesterol >7.5 + FH premature heart disease.
If total cholesterol >9 or non-HDL >7.5, refer to lipid clinic even if no FH.
Other risk factors
Be aware that there are several groups in whom QRISK2 will underestimate risk:
- People with HIV
- People with severe mental illness
- People on atypical antipsychotics
- People on corticosteroids
- People on immunosuppressants
4.9 – 9.9: Optimise other CVD risk factors, and be aware that risk assessment tools will underestimate risk. Refer if non-HDL cholesterol >7.
>10: exclude secondary causes (diabetes, hypothyroidism, alcoholism, liver disease, nephrotic syndrome) and check fasting lipids between 5 and 14 days after the initial test. If still >10 with no secondary cause, refer.
>20: refer urgently, unless result of excess alcohol or poor glycaemic control