NICE sets cholesterol target for secondary CVD prevention for first time

NICE has for the first time set a target for cholesterol levels in secondary prevention of cardiovascular disease.

Under the updated guidance, GPs are advised to keep patients’ LDL cholesterol levels at 2.0 mmol per litre or less, or non-HDL cholesterol levels of 2.6 mmol per litre or less.

Other treatments, such as ezetimibe should be considered if statins alone are not enough to hit the target, with NICE predicting the recommendations could impact up to 2.1 million people with cardiovascular disease.

All patients should be offered atorvastatin 80mg as the initial treatment, whatever their cholesterol level, unless that could react with other medications, there is a high risk of adverse events or the patient would prefer to take a lower dose, the recommendations state.

Decisions about escalating lipid-lowering treatment should be made after ‘an informed discussion between the clinician and the person’ about the risks and benefits of additional lipid-lowering treatments. Ezetimibe can be considered to reduce cardiovascular disease risk even if the lipid target is met, NICE added.

The committee noted that the targets they have set are slightly higher than others recommended in national and international guidelines but this is because the the LDL cholesterol target is based on the cost effectiveness of treatment escalation.

But in making the case, the committee said it was sufficiently similar to be reasonable and, because it was more affordable, was more likely to be implemented.

Targets set out in QOF are for a non-HDL cholesterol of 2.5 mmol/L, or where non-HDL cholesterol is not recorded, an LDL cholesterol in the preceding 12 months that is lower than 1.8 mmol/L.

The committee said that the ‘target recommended in this guideline is similar to the 2023/24 QOF, although data showed that, in many people, the QOF target is not being met’ with figures from June suggesting that 28.7% were meeting the target.

It is likely that the updated guidance will contribute to an increased workload in primary care, including for GP practices and pharmacies, as well as the labs processing cholesterol and liver function tests, NICE said.

Increased medication costs to the NHS as a result of the updated guidance would be partly offset by the savings due to the expected reduction in cardiovascular events.

Depending on how many people with uncontrolled cardiovascular disease take additional treatments, the recommendations could lead to between 50,000 and 145,000 fewer cardiovascular events over 10 years, NICE predicted.

As part of the guidance NICE has developed a new indicator to support quality improvement and which could be included in local and national ‘general practice measurement frameworks’.

Professor Jonathan Benger, NICE chief medical officer, said:‘Improving the control of cholesterol in a larger number of people will further reduce deaths from heart attacks and strokes. This guideline will help clinicians talk through the options with their patients to achieve the best outcomes.

‘We are focussed on providing useful and useable guidance for healthcare practitioners to help them and their patients make informed choices about their long-term healthcare.’

Professor Kausik Ray, professor of public health and deputy director of the Clinical Trials Unit at Imperial College London, said the lower LDL cholesterol target was welcome but noted there were ‘several discrepancies with major guidelines’.

He said most major guidelines including European Cardiology Society and American Heart Association recommend <1.8 mmol/L or ideally < 1.4mmol/L for LDL cholesterol.

‘The NHS pathways recommend also <1.8mmol/L, so we hope this does not cause confusion, especially in primary care.’