2 Implementation: getting started

This section highlights some important changes to practice that may result from implementing this guideline identified at publication in July 2014. With input from stakeholders, experts and health professionals, 3 areas have been identified that may have a big impact on practice or could be challenging to implement. However, other changes to practice may be needed to fully implement the guideline.

2.1 Measuring non-high density lipoprotein cholesterol when lipid profiling for the primary prevention of cardiovascular disease

See recommendation 1.3.4

Potential impact of implementation

Non-high density lipoprotein (non-HDL) cholesterol is seen to be a better cardiovascular disease (CVD) risk indicator than low-density lipoprotein (LDL) cholesterol. It is more accurate, more practical and cost effective. A fasting blood sample is not needed. This is more convenient for patients and may reduce the need for additional blood samples. Those requesting lipid profiles for their patients – such as GPs, practice nurses and community pharmacists – may need to change their practice. Laboratories may also need to change their reporting procedures.

Challenges for implementation

  • The United Kingdom National External Quality Assessment Service (UKNEQAS) estimated that less than 10% of laboratories included non-HDL cholesterol in their reports; however, this was primarily due to lack of demand.

  • Healthcare workers may need educating in what the non-HDL cholesterol test means, how to interpret the laboratory results, and how it compares with the previously used LDL cholesterol test.

Support for implementation

  • The Association of Clinical Biochemistry and Laboratory Medicine disseminated the updated guidance to their members – specifically clinical scientists at the laboratories – to request that they routinely include non-HDL cholesterol in their lipid profile reports. No additional equipment is needed for the non-HDL cholesterol test, other than a change to the software used when producing the report, and no extra time is needed to produce the lipid profile. Local organisations may wish to contact the laboratory they use to ensure it has this information.

  • Lab Tests Online UK updated their website to include details of the non-HDL cholesterol test in their information on lipid profiling. The information on this site explains what the test is, why it is carried out, what it involves and how to interpret the results. The website is a resource for both professionals and the public.

2.2 Reduction of the primary prevention threshold from 20% to 10% CVD risk as calculated by QRISK2

See recommendation 1.3.18

Potential impact of implementation

It is expected that there will be a reduction in the number of deaths and hospital-related admissions due to CVD events. Because the price of statins has fallen, using statins to reduce the risk of CVD at a lower threshold than NICE previously recommended is cost effective. Primary healthcare professionals may need to change their practice.

Challenges for implementation

The number of people eligible to take statins for the primary prevention of CVD will increase because of the reduction in the treatment threshold from a 20% to a 10% 10-year risk of a CVD event. The challenge is to ensure that statin treatment is presented as a patient choice in addition to lifestyle modification to avoid unnecessarily 'medicalising' this group of people. To help patients make an informed decision, healthcare professionals will need an effective way of briefly but clearly communicating the pros and cons of the various options available.

Support for implementation

  • The guideline does not propose that statins should be used instead of the lifestyle adjustments that people at risk need to make. It encourages GPs to fully explore with their patients all the options promoted by the guidance, including lifestyle changes, blood pressure control, avoidance of diabetes and cholesterol (lipid) lowering.

  • A NICE patient decision aid is available to support primary healthcare professionals in discussing the pros and cons of statin therapy with their patients so they can make an informed choice.

  • Expert opinion suggests that around 20% of these people will choose not to take statins after discussions with their healthcare professional.

  • Health practitioners may wish to refer to NICE's guideline on behaviour change on lifestyle modification.

2.3 Atorvastatin for the primary and secondary prevention of CVD

See recommendations 1.3.18, 1.3.20 and 1.3.30

Potential impact of implementation

Since the 2008 guideline on lipid modification was published, atorvastatin has come off-patent and is available at a reduced cost, therefore making it more cost effective. Atorvastatin is more potent than other non-generic statins and has a lower risk of adverse interactions with other drugs. There is also greater compatibility with other cardiovascular and lipid modifying therapies. In addition, atorvastatin does not have to be taken at night, which may increase convenience.

Challenges for implementation

  • The rationale for recommending atorvastatin over other statins may not be well understood, both when starting treatment for people with a 10% CVD risk or greater and when prescribing statins for people with existing CVD.

  • Prescribers may be uncertain about switching existing patients to atorvastatin from other statins, and may perceive there to be an impact on their workload in doing so.

Support for implementation

  • A meta-analysis of studies with statins was conducted after statins were classified into high-, medium- and low-efficacy groups based on their efficacy in lowering LDL cholesterol levels. High-efficacy statins at low acquisition cost (for example, atorvastatin 20 mg or greater) were more effective than moderate-intensity statins (simvastatin 20 mg or atorvastatin 10 mg) in reducing cardiovascular outcomes. This increment in therapy was cost effective, with high-intensity statin therapy reducing CVD events by an extra 9–12 per thousand fatal and non-fatal heart attacks and stroke events in this comparison.

  • People admitted for acute coronary syndromes are likely to have been prescribed atorvastatin 80 mg on the basis of recommendations made in the 2008 guideline. Therefore, only people with chronic CVD would need to be considered for conversion to high-dose, high-intensity statin (atorvastatin 80 mg).

  • There is no time restriction on implementing recommendation 1.3.30 with existing patients. There is no anticipated increase in workload as discussion could take place at the time of their next annual review.

2.4 Further resources

Further resources are available from NICE that may help to support implementation.

The UK National Screening Committee has agreed to reflect the 10% risk threshold in The NHS Health Check programme in line with the NICE recommendations.

NICE produces indicators annually for use in the Quality and Outcomes Framework (QOF) for the UK. The process for this and the NICE menu can be found on NICE's Quality and Outcomes Framework indicator web page.

Uptake data about guideline recommendations and quality standard measures are available on the NICE website.

  • National Institute for Health and Care Excellence (NICE)