The new guidance (CG181) reiterates the importance of preventative measures, including dietary changes, increasing exercise, stopping smoking and reducing alcohol intake, in patients at risk of CVD.
If these measures are ineffective or inappropriate, patients should be offered atorvastatin 20mg daily for primary prevention if they have a 10% or greater 10-year risk of developing CVD when assessed using the QRISK2 assessment tool.
In addition, people aged 85 years and older should be offered atorvastatin 20mg daily as this may reduce the risk of non-fatal myocardial infarction.
NICE has changed the first-choice statin from simvastatin to atorvastatin at a dose of 20mg daily for primary prevention and 80mg daily for secondary prevention. A lower dose can be considered for secondary prevention if there is the potential for interactions, a high risk of adverse reactions or if the patient prefers.
Lipids should be measured in all patients on high-intensity statin treatment (eg atorvastatin 20mg daily or greater) after 3 months, with the aim of achieving a greater than 40% reduction in non-HDL cholesterol.
Specific recommendation for diabetes and CKD
The updated guidance provides specific recommendations for patients with certain co-morbidities.
All patients with type I diabetes should be considered for statin treatment. Prescribers should offer initial treatment with atorvastatin 20mg daily to those who:
- are over 40 years old or
- have had diabetes for over 10 years or
- have established nephropathy or
- have other CVD risk factors.
Patients with type II diabetes should be offered atorvastatin 20mg daily for primary prevention if they have a 10% or greater 10-year risk of developing CVD as assessed using QRISK2.
Initial treatment with atorvastatin 20mg daily is also recommended for primary and secondary prevention in patients with chronic kidney disease. The dose may be increased if a greater than 40% reduction in LDL-C is not achieved provided the patient's eGFR is 30ml/min/1.73m2 or greater. Higher doses may be considered on the advice of a renal specialist if eGFR is less than 30ml/min/1.73m2.
Other lipid-lowering treatments not recommended
NICE no longer recommends offering fibrates, nicotinic acid, anion exchange resins/bile acid sequestrants or ezetimibe as monotherapy or in combination with a statin for the prevention of CVD. However, patients with hypercholesterolaemia should be considered for ezetimibe treatment according to the guidance issued in November 2007.
A quick-reference MIMS summary of the new guideline is available online and in the September print edition.