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Cardiovascular disease: risk assessment and reduction, including lipid modification – NICE guideline

This National Institute for Health and Care Excellence (NICE) guideline covers the assessment and care of adults who are at risk of or who have cardiovascular disease (CVD), such as heart disease and stroke. It aims to help healthcare professionals 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.

Key recommendations

Identifying and assessing cardiovascular disease (CVD) risk

  • For the primary prevention of CVD in primary care, use a systematic strategy to identify people who are likely to be at high risk. [2008, amended 2014]
  • Prioritise people for a full formal risk assessment if their estimated 10‑year risk of CVD is 10% or more. [2008, amended 2014]
  • Use the QRISK2 risk assessment tool to assess CVD risk for the primary prevention of CVD in people up to and including age 84 years. [new 2014]
  • Do not use a risk assessment tool to assess CVD risk in people with an estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m2 and/or albuminuria. These people are at increased risk of CVD. See recommendation 1.3.27 for advice on treatment with statins for people with chronic kidney disease. [new 2014]

Lipid modification therapy for the primary and secondary prevention of CVD

  • Before starting lipid modification therapy for the primary prevention of CVD, take at least one lipid sample to measure a full lipid profile. This should include measurement of total cholesterol, high‑density lipoprotein (HDL) cholesterol, non‑HDL cholesterol and triglyceride concentrations. A fasting sample is not needed. [new 2014]
  • Offer atorvastatin 20 mg for the primary prevention of CVD to people who have a 10% or greater 10‑year risk of developing CVD. Estimate the level of risk using the QRISK2 assessment tool. [new 2014]
  • 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. [new 2014]
  • 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 and 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 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. [new 2014]

Death rates from CVD peaked in the 1970s and 1980s but have more than halved since then. Rates have fallen more rapidly in older age groups compared with younger ones, with an approximately 50% reduction in the 55–64 year age group compared with a 20% reduction in men aged 35–44 years. In spite of evidence that mortality from CVD is falling, morbidity appears to be rising.

CVD shows strong age dependence and predominantly affects people older than 50 years. Risk factors for CVD include non‑modifiable factors such as:

  • age
  • sex
  • family history of CVD
  • ethnic background.

Modifiable risk factors include:

  • smoking
  • raised blood pressure
  • cholesterol.

CVD is strongly associated with low income and social deprivation and shows a north–south divide, with higher rates in the north of England.

Reasons for the guideline

This guideline includes recommendations on risk assessment for CVD and on the use of lipid‑lowering drugs. The original guideline is updated in part to allow consideration of new evidence on risk assessment tools and to reflect changes in price and availability of generic statins.

NICE has produced guidance on other modifiable risk factors for CVD and this guideline should be used in conjunction with it.

You can read the guideline on NICE's website.