Introduction

This guideline updates and replaces NICE guideline CG67 and NICE technology appraisal guidance 94. The recommendations are labelled according to when they were originally published (see update information for details).

Cardiovascular disease (CVD) describes disease of the heart and blood vessels caused by the process of atherosclerosis. It is the leading cause of death in England and Wales, accounting for almost one-third of deaths[1]. In 2010, 180,000 people died from CVD – around 80,000 of these deaths were caused by coronary heart disease and 49,000 were caused by strokes. Of the 180,000 deaths, 46,000 occurred before people were aged 75 years, and 70% of those were in men. 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 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.

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 and modifiable risk factors such as smoking, raised blood pressure and 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.

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.

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. Non‑HDL cholesterol is total cholesterol minus HDL 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 cholesterol does not.

For the purpose of this guideline, statins are grouped into 3 different intensity categories according to the percentage reduction in low‑density lipoprotein cholesterol they produce:

  • low intensity if the reduction is 20% to 30%

  • medium intensity if the reduction is 31% to 40%

  • high intensity if the reduction is above 40%.

Please see appendix A for further details. This grouping was agreed by GDG consensus, informed by analyses in the literature. See also the full guideline for a discussion of this grouping.

Drug recommendations

The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.

This guideline recommends some drugs for indications for which they do not have a UK marketing authorisation at the date of publication, if there is good evidence to support that use. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. The patient (or those with authority to give consent on their behalf) should provide informed consent, which should be documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information. Where recommendations have been made for the use of drugs outside their licensed indications ('off‑label use'), these drugs are marked with a footnote in the recommendations.

  • National Institute for Health and Care Excellence (NICE)