At a glance
- GPs should offer atorvastatin 20mg for the primary prevention of CVD to people who have a 10 per cent or greater risk of developing CVD within the next 10 years.
- Patients with type 1 or type 2 diabetes should be offered 20mg atorvastatin for primary prevention of CVD
- Patients with established CVD may need to be offered 80mg atorvastatin
- GPs should discuss the benefits of changes to lifestyle with patients before initiating treatment with statins.
- The risk of developing CVD should be estimated using the QRISK2 assessment tool.
- NICE does not believe the new guidance will increase workload for GPs.
The new recommendations mean that an additional 4.5 million people could be eligible for statins, helping to prevent up to 28,000 heart attacks and 16,000 strokes each year.
Identifying patients with CVD
The guidance recommends that GPs should take a systematic strategy to identify people who are at risk of CVD.
People should be prioritised for assessment from an estimation of their CVD risk, based on factors already documented in electronic medical records. Those aged over 40 should be reviewed on an ongoing assessment of cardiovascular risk dependent on their CVD risk estimation.
In order to assess CVD risk for primary prevention, GPs should use the QRISK2 risk calculator for patients up to and including 84 years of age.
The QRISK2 algorithm calculates the risk of having a heart attack or stroke over the next decade, based on factors such as smoking and diabetes status, ethnicity and social background.
Before starting lipid modification therapy for the primary prevention of CVD, at least 1 lipid sample should be taken to measure a full lipid profile. This should include measurement of total cholesterol, HDL cholesterol, non-HDL cholesterol and triglyceride concentrations. A fasting sample is not needed.
Preventative treatment – consider lifestyle changes first
For primary prevention of CVD, GPs should offer atorvastatin 20mg to people who have a 10 per cent or greater 10-year risk of developing CVD.
However, before offering statins for primary prevention, GPs should discuss the benefits of lifestyle modification, and optimise all other modifiable CVD factors if possible.
Patients who may need support to change their lifestyle should be referred to programmes such as exercise referral schemes.
They should then be offered the chance to have their risk of CVD assessed again after they have tried to change their lifestyle. Lifestyle adjustments recommended by NICE include being more active, quitting smoking, reducing alcohol intake, eating more healthily and losing weight.
Professor Mark Baker, Director of the Centre for Clinical Practice, said: “To make progress in the battle against heart disease and stroke, we must encourage exercise, improve our diets still further, stop smoking, and where appropriate offer statins to people at risk.
“Doctors have been giving statins to ‘well people’ since NICE first produced guidance on this in 2006. We are now recommending the threshold is reduced further. The overwhelming body of evidence supports their use, even in people at low risk of cardiovascular disease. The effectiveness of these medicines is now well proven and their cost has fallen.
“The weight of evidence clearly shows statins are safe and clinically and cost effective for use in people with a 10 per cent risk of CVD over 10 years.
“We’re not saying that everyone with a 10 per cent or greater risk of CVD within 10 years needs to take a statin. The guideline recognises the importance of choice in preventing CVD and that this should be guided by information on the trade-off between benefits and risks.”
Commenting on whether the new recommendations will create additional workload for GPs, Professor Baker added: “Most patients will already be under surveillance by their GPs so this won’t add any additional workload. But you can do the QRISK2 risk assessment yourself. It can be done online or via an app so it doesn’t need to be done by the GP.”
Dr Liam Smeeth, a GP and Professor of Clinical Epidemiology at London School of Hygiene and Tropical Medicine, said: “The recommendation from NICE to broaden the range of people who should be offered a statin within the NHS is welcome because it will help reduce the numbers of people having heart attacks and strokes.
“It is important that people are given the opportunity to have a cardiovascular risk assessment and that those people with increased risk are given appropriate information about their risk of disease and how to reduce it, including being offered a statin.”