Cardiovascular disease: risk assessment and reduction, including lipid modification

  • NICE guideline
  • NG238
  • Published: 
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Implementing lipid optimisation through prescribing strategies to reduce cardiovascular risk

Overview

Organisation: Buckinghamshire, Oxfordshire and Berkshire West integrated care board (BOB ICB)

Organisation type: NHS integrated care board

Cardiovascular disease (CVD) is the leading cause of morbidity, disability and mortality in England. It is a major driver of health inequalities and a key priority, as highlighted in the NHS Long Term Plan and the recent NHS 10 Year Health Plan. Optimising lipid management for CVD prevention has also been highlighted in the NHS England Medicines Optimisation Opportunities 2024/25 guidance and is a Core20PLUS5 health inequalities clinical area.

70% of CVD is estimated to be preventable through healthy lifestyle choices, improved detection and treatment of risk factors. Optimising treatment of high cholesterol can prevent heart attacks and strokes, with every 1 mmol/L reduction in low-density lipoprotein (LDL) cholesterol reducing the risk of major vascular events by 22% to 25% after 1 year. Chronic kidney disease (CKD) is also strongly associated with CVD. For every 100 patients with moderate-to-severe CKD, there are 6 cardiovascular events per year.

Following the introduction of NICE technology appraisals on bempedoic acid and inclisiran in 2021 and the subsequent updates of the NHS national guidance for lipid management to take account of NICE's guideline on cardiovascular disease, the lipid management pathways across Buckinghamshire, Oxfordshire and Berkshire West (BOB) were reviewed to ensure alignment. The BOB integrated care board (ICB) serves a population of approximately 1.8 million people.

National guidance had undergone significant revision to simplify treatment escalation and support clinicians to use high-intensity statins as first-line therapy. A stepwise approach using ezetimibe, PCSK9 inhibitors, bempedoic acid and inclisiran supports people at high-risk to reach lipid targets and reduce heart attacks or strokes. Local prescribing data on high-intensity statins highlighted the need for improvement.

The need for a systematic, scalable approach led the medicines optimisation team, working with the BOB system integrated cardiac delivery network (ICDN), to focus on lipid optimisation in primary care through the prescribing quality scheme. The BOB long-term conditions ICDN works collaboratively with a range of partners, including NHS trusts, local authorities and Health Innovation Oxford and Thames Valley, with the aim of CVD prevention and reducing inequalities through co-designing integrated pathways.

Prescribing quality scheme

The BOB ICB medicines optimisation team have run an annual ICB-wide scheme since August 2022. The scheme supports primary care to embed evidence-based, safer prescribing aligned to national priorities and guidance to improve the outcomes for patients.

Across 3 years (2022 to 2025), the scheme included annual CVD-focused targets relating to lipid optimisation on high-intensity statins and support inappropriate escalation through the lipid management pathway.

Primary prevention (2022 to 2023, Year 1):

  • Identified patients with QRISK higher than 20% taking low- or medium-intensity statins.

  • Practices reviewed patients to determine appropriateness of switching to a high-intensity statin.

Secondary prevention (2023 to 2024, Year 2):

  • Identified patients aged under 80 years prescribed a suboptimal statin (simvastatin, fluvastatin or pravastatin).

  • Practices reviewed and optimised therapy to high-intensity statins or maximum tolerated doses.

Primary prevention in CKD (2024 to 2025, Year 3):

  • Identified patients aged 18 to 75 with coded CKD stage 3 not currently prescribed any lipid-lowering therapy.

  • Practices reviewed and initiated treatment where clinically appropriate.

To support the prescribing quality scheme, the medicines optimisation team:

  • developed resource packs required to undertake the target, including clinical system searches, clinical background guidance and audit templates

  • signposted to shared decision-making tools to support patient conversations with a shared decision-making approach

  • ran primary care educational sessions with specialist clinicians at scheme launch. Alongside these sessions, the BOB system cardiac network also supported workforce training through a series of lipid management webinars

  • enabled clinical decision support tool messages, which support lipid optimisation pathways

  • reviewed all anonymised evidence submitted by the practices and offered guidance and support where required. The learning outcomes were reported back to the cardiac network to inform the development of further system work to support CVD prevention.

The scheme was complemented by broader work carried out within the medicines optimisation team and through the cardiac network, which included:

  • a single BOB integrated care system (ICS) lipid modification guideline to reflect NICE's guideline on cardiovascular disease and the national lipid pathway, with subsequent updates to support prescribing decisions

  • resources for clinicians, including an inclisiran primary care resource pack for practices, and an inclisiran patient information leaflet to aid discussions between people and their healthcare professional

  • the development of a locally enhanced service which included inclisiran administration

  • delivering a series of lipid management webinars to support lipid optimisation

  • a series of animated cholesterol videos and leaflets, translated into 6 languages. This was developed by Health Innovation Oxford and Thames Valley with patients and clinicians, with collaborators including Heart UK and NHS England.

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