Update information

September 2016: Recommendation 1.3.28 was amended to clarify what was meant by high-intensity statin treatment, and that the recommendation applies to both primary and secondary prevention. The term 'high-intensity statin' was also added to the 'Terms used in this guideline' section and linked to throughout.

July 2016: Amended recommendation 1.2.2 to clarify the advice on saturated and monounsaturated fat.

December 2015: Changes to update information and related NICE guidance sections and recommendation labelling following publication of the updated NICE guideline on type 2 diabetes in adults.

August 2015: Changes to recommendation labelling, footnote 7, and update information and related NICE guidance sections following publication of updated NICE guidelines on chronic kidney disease and type 1 diabetes in adults (references to CG73 and CG15 have been removed because these have been replaced).

January 2015: New section Implementation: getting started added.

January 2015: Minor change to appendix B of the full guideline.

July 2014: This guideline updates and replaces NICE guideline CG67 (published September 2008). It also updates and replaces recommendations relating to statin therapy for people at increased risk of developing cardiovascular disease or those with established cardiovascular disease:

Recommendations are marked as [new 2014], [2014], [2008] or [2008, amended 2014]:

  • [new 2014] indicates that the evidence has been reviewed and the recommendation has been added or updated

  • [2014] indicates that the evidence has been reviewed but no change has been made to the recommended action

  • [2008] indicates that the evidence has not been reviewed since 2008

  • [2008, amended 2014] indicates that the evidence has not been reviewed since 2008, but changes have been made to the recommendation wording that change the meaning (see below).

Recommendations from NICE guideline CG67 that have been amended

Recommendations are labelled [2008, amended 2014] if the evidence has not been reviewed since 2008 but changes have been made to the recommendation wording that change the meaning.

Recommendation in 2008 guideline

Recommendation in current guideline

Reason for change

1.1.1 For the primary prevention of CVD in primary care, a systematic strategy should be used to identify people aged 40–74 who are likely to be at high risk.

1.1.1 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]

The tools available for estimating CVD risk in 2008 had an upper age range of 74 years. QRISK2 has an upper age range of 84 years. The age range was therefore removed for clarity.

1.1.4 People should be prioritised for a full formal risk assessment if their estimated 10-year risk of CVD is 20% or more.

1.1.4 Prioritise people for a full formal risk assessment if their estimated 10‑year risk of CVD is 10% or more. [2008, amended 2014]

The threshold for treatment has been changed from 20% to 10% because of new health economics results.

1.1.10 Risk equations should not be used for people with pre‑existing:

  • CHD or angina

  • stroke or transient ischaemic attack

  • peripheral vascular disease.

1.1.15 Do not use a risk assessment tool for people with pre‑existing CVD. [2008, amended 2014]

The GDG made this recommendation more general to include all CV diseases.

1.1.11 Risk equations should not be used for people who are already considered at high risk of CVD because of:

  • familial hypercholesterolaemia or other monogenic disorders of lipid metabolism

  • diabetes, see 'type 2 diabetes: the management of type 2 diabetes (update)' (NICE guideline CG66).

1.1.16 Do not use a risk assessment tool for people who are at high risk of developing CVD because of familial hypercholesterolaemia (see Familial hypercholesterolaemia [NICE guideline CG71]) or other inherited disorders of lipid metabolism. [2008, amended 2014]

The bullet point about type 2 diabetes has been deleted because the GDG made separate specific recommendations for this subgroup.

1.1.13 When using the risk score to inform drug treatment decisions, particularly if it is near to the threshold of 20%, healthcare professionals should consider other

factors that:

  • may predispose the person to premature CVD, and

  • may not be included in calculated risk scores.

1.1.17 When using the risk score to inform drug treatment decisions, particularly if it is near to the threshold for treatment, take into account other factors that:

  • may predispose the person to premature CVD and

  • may not be included in calculated risk scores. [2008, amended 2014]

The threshold for treatment has been changed because of new health economics results.

'healthcare professionals should consider'

has been amended to:

'take into account'

in line with current NICE style for recommendations in guidelines.

1.1.20 CVD risk may be underestimated in people who are already taking antihypertensive or lipid modification therapy, or who have recently stopped smoking. Clinical judgement should be used to decide on further treatment of risk factors in people who are below the 20% CVD risk threshold.

1.1.19 Recognise that CVD risk will be underestimated in people who are already taking antihypertensive or lipid modification therapy, or who have recently stopped smoking. Use clinical judgement to decide on further treatment of risk factors in people who are below the CVD risk threshold for treatment. [2008, amended 2014]

The threshold for treatment has been changed because of new health economics results.

1.1.21 CVD risk scores may not be appropriate as a way of assessing risk in people who are at increased CVD risk because of underlying medical conditions or treatments. These include people treated for HIV or with antipsychotic medication, people with chronic kidney disease and people with autoimmune disorders such as systemic lupus erythematosus (SLE) and rheumatoid arthritis.

1.1.18 Recognise that standard CVD risk scores will underestimate risk in people who have additional risk because of underlying medical conditions or treatments. These groups include:

  • people treated for HIV

  • people with serious mental health problems

  • people taking medicines that can cause dyslipidaemia such as antipsychotic medication, corticosteroids or immunosuppressant drugs

  • people with autoimmune disorders such as systemic lupus erythematosus and other systemic inflammatory disorders. [2008, amended 2014]

The list of underlying medical conditions had been updated.

1.1.22 People aged 75 or older should be considered at increased risk of CVD, particularly people who smoke or have raised blood pressure. They are likely to benefit from statin treatment. Assessment and treatment should be guided by the benefits and risks of treatment, informed preference and comorbidities that may make treatment inappropriate.

1.1.21 Consider people aged 85 or older to be at increased risk of CVD because of age alone, particularly people who smoke or have raised blood pressure. [2008, amended 2014]

'should be considered'

has been amended to:

'consider'

in line with current NICE style for recommendations in guidelines.

The age value has been changed to 85, as this is the upper limit of the QRISK2 assessment tools.

The part on treatment has been deleted, as recommendations on treatment are listed in section 1.3.

1.2.5 In order to encourage the person to participate in reducing their CVD risk, the healthcare professional should:

  • find out what, if anything, the person has already been told about their CVD risk and how they feel about it

  • explore the person's beliefs about what determines future health (this may affect their attitude to changing risk)

  • assess their readiness to make changes to their lifestyle (diet, physical activity, smoking and alcohol consumption), to undergo investigations and to take medication

  • assess their confidence in making changes to their lifestyle, undergoing investigations and taking medication

  • inform them of potential future management based on current evidence and best practice

  • involve them in developing a shared management plan

  • check with them that they have understood what has been discussed.

1.1.27 To encourage the person to participate in reducing their CVD risk:

  • find out what, if anything, the person has already been told about their CVD risk and how they feel about it

  • explore the person's beliefs about what determines future health (this may affect their attitude to changing risk)

  • assess their readiness to make changes to their lifestyle (diet, physical activity, smoking and alcohol consumption), to undergo investigations and to take long‑term medication

  • assess their confidence in making changes to their lifestyle, undergoing investigations and taking medication

  • inform them of potential future management based on current evidence and best practice

  • involve them in developing a shared management plan

  • check with them that they have understood what has been discussed. [2008, amended 2014]

The words 'long‑term' have been added to the third bullet in relation to medication to emphasise the need to discuss people's views about taking medication long term.

1.2.7 If the person's CVD risk is considered to be at a level that merits intervention but they decline the offer of treatment, they should be advised that their CVD risk should be considered again in the future.

1.1.28 If the person's CVD risk is at a level where intervention is recommended but they decline the offer of treatment, advise them that their CVD risk should be reassessed again in the future. Record their choice in their medical notes. [2008, amended 2014]

The GDG considered it important that people's involvement in decision‑making and their choices are adequately recorded.

1.3.7 People at high risk of CVD or with CVD should be advised to take 30 minutes of physical activity a day, of at least moderate intensity, at least 5 days a week, in line with national guidance for the general population. (see Physical activity guidelines for adults) [2008,]

1.2.7 Advise people at high risk of or with CVD to do the following every week:

  • at least 150 minutes of moderate intensity aerobic activity or

  • 75 minutes of vigorous intensity aerobic activity or

  • a mix of moderate and vigorous aerobic activity

in line with national guidance for the general population (see Physical activity guidelines for adults at NHS Choices). [2008, amended 2014]

This recommendation has been updated because the chief medical officer issued changes to recommendations on physical activity in 2011.

1.3.8 People who are unable to perform moderate‑intensity physical activity at least 5 days a week because of co‑morbidity, medical conditions or personal circumstances should be encouraged to exercise at their maximum safe capacity. [2008]

1.2.9 Encourage people who are unable to perform moderate‑intensity physical activity because of comorbidity, medical conditions or personal circumstances to exercise at their maximum safe capacity. [2008, amended 2014]

This recommendation has been updated because the chief medical officer issued changes to recommendations on physical activity in 2011.

1.4.18 If a person has acute coronary syndrome, statin treatment should not be delayed until lipid levels are available. A fasting lipid sample should be taken about 3 months after the start of treatment.

1.3.22 If a person has acute coronary syndrome, do not delay statin treatment. Take a lipid sample on admission and about 3 months after the start of treatment. [2008, amended 2014]

The GDG considered that a fasting sample is not necessary if non‑HDL cholesterol is measured (see recommendation 1.3.4).

The GDG wished to highlight the importance of taking a lipid sample also on admission.

  • National Institute for Health and Care Excellence (NICE)