NICE guidance - statin treatment in the prevention of cardiovascular disease (CVD)

Last reviewed 04/2023

NICE appraisal states that statin therapy (1):

• atorvastatin 20mg per day is the statin used in primary prevention
  • offer atorvastatin 20 mg for the primary prevention of CVD to people who have a 10% or greater 10-year risk of developing CVD
  • estimate the level of risk using the QRISK2 assessment tool:
  • use the QRISK2 risk assessment tool to assess CVD risk for the primary prevention of CVD in people up to and including age 84 years
    • do not use a risk assessment tool to assess CVD risk in people with type 1 diabetes
    • use the QRISK2 risk assessment tool to assess CVD risk in people with type 2 diabetes
    • do not use a risk assessment tool to assess CVD risk in people with an estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m2 and/or albuminuria -these people are at increased risk of CVD
    • do not use a risk assessment tool for people with pre-existing CVD
    • do not use a risk assessment tool for people who are at high risk of developing CVD because of familial hypercholesterolaemia or other inherited disorders of lipid metabolism
    • when using the risk score to inform drug treatment decisions, particularly if it is near to the threshold for treatment, take into account other factors that:
      • may predispose the person to premature CVD and
      • may not be included in calculated risk scores
    • recognise that standard CVD risk scores will underestimate risk in people who have additional risk because of underlying medical conditions or treatments. These groups include:
      • people treated for HIV
      • people with serious mental health problems
      • people taking medicines that can cause dyslipidaemia such as antipsychotic medication, corticosteroids or immunosuppressant drugs
      • people with autoimmune disorders such as systemic lupus erythematosus, and other systemic inflammatory disorders
    • recognise that CVD risk will be underestimated in people who are already taking antihypertensive or lipid modification therapy, or who have recently stopped smoking. Use clinical judgement to decide on further treatment of risk factors in people who are below the CVD risk threshold for treatment
    • severe obesity (body mass index greater than 40 kg/m2) increases CVD risk. Take this into account when using risk scores to inform treatment decisions in this group
    • consider people aged 85 or older to be at increased risk of CVD because of age alone, particularly people who smoke or have raised blood pressure
      
      

Target:

• measure total cholesterol, HDL cholesterol and non-HDL cholesterol in all people who have been started on high-intensity statin treatment at 3 months of treatment and aim for a greater than 40% reduction in non-HDL cholesterol. If a greater than 40% reduction in non-HDL cholesterol is not achieved:

  • discuss adherence and timing of dose
  • optimise adherence to diet and lifestyle measures
  • consider increasing dose if started on less than atorvastatin 80 mg and the person is judged to be at higher risk because of comorbidities, risk score or using clinical judgement

Notes:

• Dose of particular statin versus reduction in LDL cholesterol

  Dose (mg/day)	5	10	20	40	80
  fluvastatin	-	-	21% a	27% a	33% b
  pravastatin	-	20% a	24% a	29% a	-
  simvastatin	-	27% a	32% b	37% b	42% c,d
  atorvastatin	-	37% b	43% c	49% c	55% c
  rosuvastatin	38% b	43% c	48% c	53% c	-

  • a 20%- 30%: low intensity
    
    
  • b 31%- 40%: medium intensity
    
    
  • c Above 40%: high intensity
    
    
  • d Advice from the MHRA: there is an increased risk of myopathy associated with high-dose (80 mg) simvastatin. The 80 mg dose should be considered only in patients with severe hypercholesterolaemia and high risk of cardiovascular complications who have not achieved their treatment goals on lower doses, when the benefits are expected to outweigh the potential risks.

   

Reference:

• (1) NICE (May 2014).Lipid modification - Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease