primary prevention of coronary heart disease

Last reviewed 02/2021

This section relates to primary prevention of coronary heart disease (CHD) in individuals at high absolute risk of developing CHD, or other major atherosclerotic disease, because of hypertension, dyslipidaemia, family history of premature CHD, smoking or a combination of these and other risk factors. Patients with diabetes mellitus are at particularly high risk.

Identifying and assessing cardiovascular disease (CVD) risk

• 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 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 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 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
• 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

Lipid modification therapy for the primary and secondary prevention of CVD

• before starting lipid modification therapy for the primary prevention of CVD, take at least 1 lipid sample to measure a full lipid profile
  • should include measurement of total cholesterol, high-density lipoprotein (HDL) cholesterol, non-HDL cholesterol, and triglyceride concentrations (fasting sample is not required)
• atorvastatin 20 mg should be offered 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
• if a person has CVD then start statin treatment in people with CVD with atorvastatin 80 mg . A lower dose of atorvastatin if any of the following apply:
  • potential drug interactions
  • high risk of adverse effects
  • patient preference

Target cholesterol level

• 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

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