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NICE raises the bar with new lipid targets of 4 and 2

By Daniel Cressey

GPs will be expected to aggressively treat cholesterol levels in all patients with cardiovascular disease as part of sweeping changes to national guidelines

Draft NICE guidance on lipid modification raises the bar on secondary prevention of CVD by asking GPs to lower total and LDL cholesterol to 4 and 2mmol/l or below respectively.

GPs are being asked to titrate up statin doses whenever patients don't hit these thresholds, although the institute did acknowledge doubts over 'ultra-low' targets by conceding an 'audit' total cholesterol level of 5mmol/l could be used to assess progress at a population level.

But for primary prevention the guidance moved away from the concept of targets altogether, instead backing a fire and forget strategy using 40mg simvastatin or pravastatin.

The institute wants all patients over 40 to be regularly and systematically reviewed in primary care – but insists it is not recommending a full screening programme.

NICE has shrugged aside doubts over the Framingham risk score by placing it at the centre of its monitoring strategy, but the institute does recommend a series of adjustments for those whose risk is currently underestimated.

GPs should multiply estimates of risk by at least 1.5 times for family history and by 1.4 times in south Asian men, and should also consider adjusting risk upwards in individuals from deprived backgrounds.

Statins are recommended for all adults with a 20% or greater 10-year CVD risk, in line with last year's technology appraisal.

The institute has backed the national push for use of cheap statins by promoting use of simvastatin 40mg or 'a drug of comparable effectiveness and acquisition cost'.

Dr Stewart Findlay, treasurer of the Primary Care Cardiovascular Society and a GP in Bishop Auckland, Co. Durham, said: 'Many of us think for secondary prevention 4 and 2 is the correct target to go for. I'm slightly surprised, in view of affordability, that they have gone for it.'

But Dr Findlay expressed disappointment that no target was set for primary prevention.

The guidance will be out to consultation until 22 August.

Key points

RISK ASSESSMENT
• Framingham risk tool to be used to assess 10-year CVD risk
• Estimates adjusted by 1.5 to 2.0-fold for family history and 1.4-fold for south Asian men
• GPs should take into account deprivation and other drug treatments that may lead to underestimation of risk
• People over 40 should be reviewed on ongoing basis in primary care using Framingham

TREATMENT
• Simvastatin 40mg or pravastatin 40mg recommended for primary prevention in all patients with a 20% or greater 10-year CVD risk
• No targets for primary prevention – fire and forget strategy, but with liver function tests at six and 12 months
• Simvastatin 40mg should normally be used initially for secondary prevention, with uptitration if patients don't hit targets of 4 and 2mmol/l
• 'Audit' level of total cholesterol of 5mmol/l can be used

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