22 September 2015

Improving the treatment of cardiovascular disease

NICE says adults with a 10-year risk of cardiovascular disease (CVD) of 10 per cent or more should be given advice on lifestyle changes before any statin therapy is offered.

The advice comes from NICE’s new quality standard on cardiovascular risk assessment and lipid modification, which follows guidance on statins that was published last year.

CVD is the leading cause of death in England and Wales, accounting for almost a third of all deaths.

Mortality rates from CVD have been falling in recent years due to a reduction in risk factors such as smoking. However morbidity appears to be rising, costing the NHS an estimated £7,880 million in 2010. People in certain parts of the country are also more likely to have the condition than others, as it is strongly associated with low income and social deprivation.

The NICE quality standard on CVD risk assessment and lipid modification helps to improve the care and treatment of patients with CVD and make it more consistent. It consists of 9 statements that together aim to tackle the incidence of CVD events, mortality from CVD, and patient experience of GP services.

Use QRISK2 for formal risk assessment

A formal risk assessment is the most accurate method of targeting prevention strategies to improve clinical outcomes for adults with an estimated increased risk of CVD.

As a result the first statement calls for adults under 85 years with an estimated increased risk of CVD to be offered a full formal risk assessment using the QRISK2 tool.

The QRISK2 tool is an online assessment tool for estimating the 10-year risk of having a CVD event in those who do not have the disease. This can then be used to inform treatment decisions such as lifestyle advice or drug treatment.

Offer advice on lifestyle changes before offering statin therapy

Lifestyle changes such as stopping smoking, increasing physical activity, and maintaining a healthy diet are effective methods of reducing the risk of CVD.

Consequently, the quality standard says adults with a 10‑year risk of cardiovascular disease (CVD) of 10% or more should receive advice on lifestyle changes before any offer of statin therapy.

NICE says that lifestyle changes can reduce a person’s risk of CVD without the need for drug treatment. Furthermore, it is important that the benefits of lifestyle changes for primary prevention are discussed with adults at risk of CVD, to encourage uptake of lifestyle interventions before any offer of statin therapy.

Statement 4 says that GPs should discuss the risks and benefits of starting statin therapy with adults who have a 10‑year risk of cardiovascular disease (CVD) of 10% or more for whom lifestyle changes are ineffective or inappropriate.

This is because people who are better informed and involved in decisions about their care are more likely to adhere to their chosen treatment plan which improves patient and clinical outcomes.

Initiating statin therapy

Adults choosing statin therapy for the primary prevention of CVD should be offered atorvastatin 20mg, and adults with newly diagnosed CVD should be offered atorvastatin 80mg.

The use of high-intensity statins can cause side effects, but to improve clinical outcomes it is important that alternative strategies are tried rather than stopping treatment.

As a result, statement 7 says adults on a high-intensity statin who have side effects are offered a lower dose or an alternative statin.

This month NICE also published a quality standard on secondary prevention after a myocardial infarction (MI), one of the most severe presentations of coronary heart disease.

The quality standard includes a statement on communication with primary care. It says adults admitted to hospital with an MI have the results of the investigations and a plan for future treatment and monitoring shared with their GP.

NICE says clear communication of these results to primary care in a discharge summary ensures that people receive the right treatment after they leave hospital.