Quality statement 2: Excluding secondary causes

Quality statement

Adults with a 10‑year risk of cardiovascular disease (CVD) of 10% or more are assessed for secondary causes before any offer of statin therapy.

Rationale

Several conditions can increase a person's risk of CVD, which may also cause dyslipidaemia (abnormal lipid levels). It is important that these are identified before starting statin therapy, which can cause side effects in adults with certain conditions. Common secondary causes of increased risk of CVD or dyslipidaemia include uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome.

Quality measures

Structure

Evidence of local arrangements to ensure that adults with a 10‑year risk of CVD of 10% or more are assessed for secondary causes before any offer of statin therapy.

Data source: Local data collection.

Process

Proportion of adults with a 10‑year risk of CVD of 10% or more who are assessed for secondary causes before any offer of statin therapy.

Numerator – the number in the denominator who are assessed for secondary causes before any offer of statin therapy.

Denominator – the number of adults with a 10‑year risk of CVD of 10% or more.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (primary care) should ensure that adults with a 10‑year risk of CVD of 10% or more are assessed for secondary causes before offering statin therapy. This assessment should be recorded and made available for any monitoring requests.

Healthcare professionals assess adults with a 10‑year risk of CVD of 10% or more for secondary causes before offering statin therapy.

Commissioners (NHS England area teams and clinical commissioning groups) ensure that GPs in their locality are aware of the need for adults with a 10‑year risk of CVD of 10% or more to be assessed for secondary causes before offering statin therapy. Commissioners should include this requirement in any relevant local enhanced service specifications (for example, cardiovascular), according to local arrangements.

What the quality statement means for patients, service users and carers

Adults with a 1 in 10 or more chance of developing CVD in the next 10 years (a 10‑year risk of 10% or more) are checked to see if there are any underlying causes before being offered treatment with a medicine called a statin. This will indicate whether there is another reason for their increased risk that might need a different treatment.

Source guidance

Definitions of terms used in this quality statement

Assessment for secondary causes

Secondary causes of increased CVD risk and dyslipidaemia include excess alcohol use, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome. An assessment for secondary causes of CVD risk or dyslipidaemia should include:

  • smoking status

  • alcohol consumption

  • blood pressure

  • body mass index

  • HbA1c

  • renal function and estimated glomerular filtration rate (eGFR)

  • transaminase level

  • thyroid‑stimulating hormone.

[Lipid modification (NICE guideline CG181) recommendations 1.3.6, 1.3.13]

Equality and diversity considerations

The statement includes adults with a 10‑year risk of CVD of 10% or more, as determined by their QRISK2 score if they are under 85 years. Adults aged 85 years and older should be considered to be at high risk based on age alone, particularly those who smoke or have high blood pressure. Because QRISK2 calculates a person's CVD risk over the next 10 years, its risk scores may underestimate risk in younger people or women who have additional risk because of underlying medical conditions, such as serious mental health problems or severe obesity (body mass index greater than 40 kg/m2). When using a QRISK2 risk score to inform drug treatment decisions in these populations, particularly if it is near the threshold for treatment, take into account other factors that may predispose the person to premature CVD that may not be included in calculated risk scores.