NICE says doctors should consider many more people to be at risk of cardiovascular disease (CVD) which causes 1 in 3 deaths in the UK (180,000 each year).

NICE advises that the threshold for starting preventive treatment of these conditions should be halved from a 20% risk of developing CVD over 10 years to a 10% risk. Prevention includes stopping smoking, reducing alcohol consumption, taking exercise and eating a healthy diet. Once these factors have been addressed, the guidance says high intensity statin therapy should be offered.

People can be at risk from CVD because of factors they cannot change including their age, sex, ethnicity, and family history. The guidance recommends that risk factors which can be addressed should be managed.

Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, says: “To make progress in the battle against heart disease and stroke, we must encourage exercise, improve our diets still further, stop smoking, and where appropriate offer statins to people at risk.

“Doctors have been giving statins to ‘well people’ since NICE first produced guidance on this in 2006. We are now recommending the threshold is reduced further. The overwhelming body of evidence supports their use, even in people at low risk of cardiovascular disease. The effectiveness of these medicines is now well proven and their cost has fallen.

“The weight of evidence clearly shows statins are safe and clinically and cost effective for use in people with a 10% risk of CVD over 10 years.

“We’re not saying that everyone with a 10% or greater risk of CVD within 10 years needs to take a statin. The guideline recognises the importance of choice in preventing CVD and that this should be guided by information on the trade-off between benefits and risks.”

By recommending a systematic approach to identifying those at risk of CVD, the guideline will enable people to access treatments to address that risk by reducing their cholesterol levels.

 It will also provide further clarity for practitioners in primary and secondary care about how to manage patients both with and without pre-existing cardiovascular disease.

NICE recommends that people are assessed (using the QRISK2 calculator) for their risk of developing cardiovascular disease using measurements including whether or not they smoke, their cholesterol levels, blood pressure, and body mass index. The calculator then provides a percentage risk of developing CVD in the next 10 years.

“This new guideline complements the NHS Health checks programme in helping to identify people at future risk of developing cardiovascular disease at a stage at which lifestyle modification can make a significant difference” says Guideline Development Group Chair Dr Anthony Wierzbicki.

“It updates and simplifies treatment protocols for people with established CVD, with diabetes or kidney disease so that these people can derive maximum benefit from lipid-lowering therapies.”

Liz Clark, a lay member of the Guideline Development Group, said: “One of the key challenges is how to convince people who feel well that they need to make substantial lifestyle changes or that they benefit from lifelong drug treatment.  This requires high quality information and communication on the benefits and risks of these therapies and this is reflected in the guideline.

“The guideline therefore places patients centrally in any decision making about their management and it emphasises the need to address all CVD risk factors in combination.

“It highlights the need for doctors to encourage people to participate in reducing their CVD risk. For example, it recommends that doctors assess a person’s readiness and confidence to make changes to their diet, level of physical activity and smoking and alcohol consumption, as well as taking long-term medication. It also recommends that people are involved in developing a shared management plan.”

ENDS

Notes to Editors                     

About the guideline

1. The NICE clinical guideline on lipid modification will be available from the NICE website from Friday 18 July 2014. 

2. Key recommendations in the guideline include:

• For the primary prevention of CVD in primary care, use a systematic strategy to identify people who are likely to be at high risk.
• Prioritise people for a full formal risk assessment if their estimated 10-year risk of CVD is 10% or more.
• 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.  
• 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.
• Start statin treatment in people with CVD with atorvastatin 80 mg. If any of the following apply use a lower dose of atorvastatin:
  -   potential drug interactions
  -   high risk of adverse effects
  -   patient preference.

• Measure total cholesterol, HDL cholesterol and non-HDL cholesterol in all people who have been started on high-intensity statin treatment 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.

About CVD

3. Of the 180,000 deaths from CVD in 2010, 46,000 occurred before people were aged 75 years, and 70% of those were in men.

4. Around 80,000 of these deaths were caused by coronary heart disease and 49,000 were caused by strokes.

5. Death rates from CVD peaked in the 1970s and 1980s but have since been falling and have now more than halved. 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.

6. In spite of evidence that mortality from CVD is falling, morbidity appears to be rising. CVD has significant cost implications and was estimated to cost the NHS in England almost £6,940 million in 2003 rising to £7,880 million in 2010.

7. CVD shows strong age dependence and predominantly affects people over 50 years. Risk factors for CVD include non-modifiable factors such as age, gender, family history of CVD, ethnic background and modifiable risk factors such as smoking, raised blood pressure and cholesterol.

8. CVD is strongly associated with low income and social deprivation and shows a North-South divide with higher rates in the north of England.

9. Cardiovascular disease develops when fatty substances build up in the coronary arteries and narrow them. The deposits (known as atheroma) are made up of lipids (cholesterol and other fats), calcium and fibrous tissue. As people age, the deposits of atheroma can form into plaques, and in some people the arteries in the heart, brain and legs become severely narrowed, and diseased. Depending on where the disease develops, it can be called coronary heart disease (heart), stroke (neck or brain), or peripheral arterial disease (pelvis and legs).

10. As many as 7 million people in the UK are currently believed to take statins, at an estimated annual cost of £150 million.

About NICE

The National Institute for Health and Care Excellence (NICE) is the independent body responsible for driving improvement and excellence in the health and social care system. We develop guidance, standards and information on high-quality health and social care. We also advise on ways to promote healthy living and prevent ill health.

Formerly the National Institute for Health and Clinical Excellence, our name changed on 1 April 2013 to reflect our new and additional responsibility to develop guidance and set quality standards for social care, as outlined in the Health and Social Care Act (2012).

Our aim is to help practitioners deliver the best possible care and give people the most effective treatments, which are based on the most up-to-date evidence and provide value for money, in order to reduce inequalities and variation.

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