Saturday, 15 February 2014

Lipid modification : Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. NICE guideline: Draft for consultation, February 2014

reposted from:

(NB. full guidance: (not reviewed here))

My Key points (my highlights):-

  • [1.3.16] Offer atorvastatin 20 mg for the primary prevention of CVD. [new 2014] 
  • Use the QRISK2 risk assessment tool to assess CVD risk for the primary prevention of CVD. [new 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. [new 2014] 
  • Further information and advice on healthy cooking methods can be found at NHS Choices. [new 2014] 
  • Before starting lipid modification therapy for the primary prevention of CVD, take at least 1 lipid sample to measure a full lipid profile. This should include measurement of total cholesterol, HDL cholesterol, non-HDL cholesterol, and triglyceride concentrations. A fasting sample is not needed. [new 2014] 
  • Use the clinical findings, lipid profile and family history to judge the likelihood of a familial lipid disorder rather than the use of strict lipid cut-off values alone. [new 2014] 
  • In this update the Guideline Development Group (GDG) recommend the use of non-high density lipoprotein (non-HDL) cholesterol rather than low density lipoprotein (LDL) cholesterol. LDL cholesterol is not directly measured but requires a calculation using a fasting sample and for triglyceride levels to be less than 4.5 mmol/litre, whereas the measurement of non-HDL does not. 
  • Follow-up of people initiated on statin treatment 
  • 1.3.29 Measure cholesterol, HDL cholesterol and non-HDL cholesterol in people who have been started on high-intensity statin treatment after 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 (take at night) 
    • optimise adherence to diet and lifestyle measures 
    • consider increasing dose if started on less than atorvastatin 80 mg and person is judged to be at higher risk because of comorbidities, risk score or using clinical judgement. [new 2014] 
  • 1.3.38 Before offering a statin, ask the person if they have had persistent generalised unexplained muscle pain, whether associated or not with previous lipid-lowering therapy, and if present, measure creatine kinase levels. If these are elevated start statin treatment at a lower dose. [new 2014]
  • 1.3.42 Measure baseline liver transaminase enzymes (alanine aminotransferase or aspartate aminotransferase) before starting a statin. Measure liver transaminase (alanine aminotransferase or aspartate aminotransferase) within 3 months of starting treatment and at 12 months, but not again unless clinically indicated. [2008, amended 2014] 
  • 1.3.50 Tell people that there is no evidence that omega-3 fatty acid compounds help to prevent CVD. [new 2014] 
  • Combination therapy for preventing CVD 
    • 1.3.51 Do not offer the combination of a bile acid sequestrant (anion exchange resin), fibrate, nicotinic acid or omega-3 fatty acid compound with a statin for the prevention of CVD. [new 2014] 
  • Appendix B: Grouping of statins 
For the purpose of this guideline, statins are grouped into 3 different intensity categories according to the percentage reduction in low-density lipoprotein cholesterol (see table 1). This grouping was agreed by GDG consensus, informed by analyses in the literature. See the full guideline for a discussion of this grouping. 


Crabsallover Change in Statin Use

Switch from Simvastin 10mg/day = 27% reduction in low-density lipoprotein cholesterol, where low intensity = 20%-30%, to Atorvastatin 20mg/day = 43% high intensity (>40%). NB. Medium intensity (31%-40%)

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