Management

In 2014 NICE updated their guidelines on lipid modification. This proved highly controversial as it meant that we should be recommending statins to a significant proportion of the population over the age of 60 years. Anyway, the key points of the new guidelines are summarised below.

Primary prevention - who and how to assess risk

A systematic strategy should be used to identify people aged over 40 years who are likely to be at high risk of cardiovascular disease (CVD), defined as a 10-year risk of 10% or greater.

NICE recommend we use the QRISK2 CVD risk assessment tool for patients aged <= 84 years. Patients >= 85 years are at high risk of CVD due to their age. QRISK2 should not be used in the following situations as there are more specific guidelines for these patient groups:

• type 1 diabetics
• patients with an estimated glomerular filtration rate (eGFR) less than 60 ml/min and/or albuminuria
• patients with a history of familial hyperlipidaemia

NICE suggest QRISK2 may underestimate CVD risk in the following population groups:

• people treated for HIV
• people with serious mental health problems
• people taking medicines that can cause dyslipidaemia such as antipsychotics, corticosteroids or immunosuppressant drugs
• people with autoimmune disorders/systemic inflammatory disorders such as systemic lupus erythematosus

Measuring lipid levels

When measuring lipids both the total cholesterol and HDL should be checked to provide the most accurate risk of CVD. A full lipid profile should also be checked (i.e. including triglycerides) before starting a statin. The samples do not need to be fasting.

In the vast majority of patients the cholesterol measurements will be fed into the QRISK2 tool. If however, the patient's cholesterol is very high we should consider familial hyperlipidaemia. NICE recommend the following that we should consider the possibility of familial hypercholesterolaemia and investigate further if:

• the total cholesterol level greater than 7.5 mmol/L and/or