NICE guidelines for lipid lowering

General

Clinical Question:
What does the British National Institute of Clinical Effectiveness (NICE) recommend regarding the treatment of patients at risk for cardiovascular disease and elevated lipid levels?

Bottom Line:
It's the baseline risk, not the baseline lipid levels, that is of primary importance when making decisions about lipid lowering treatment, according to NICE. For patients with elevated lipids but without heart disease, the guidelines suggest initiating treatment only if patients have a 10-year risk of 20%. A calculator is available to calculate this risk in Essential Evidence Plus. For this primary prevention, they suggest a hands-off approach of treating with simvastatin 40 mg daily and not checking follow-up cholesterol. For patients with heart disease, they suggest starting with the same dose but checking response and increasing the dose when necessary. They apply these guidelines to men and women, though cholesterol treatment in women has not been shown to be decrease mortality. (LOE = 5)

Reference:
Cooper A, O'Flynn N. Risk assessment and lipid modification for primary and secondary prevention of cardiovascular disease: summary of NICE guidance. BMJ 2008;336:1246-1248.  [PMID:18511800]

Study Design:
Practice guideline

Setting:
Various (guideline)

Synopsis:
The British NICE guidelines are derived from systematic reviews, supplemented, when minimal evidence is available, with recommendations based on expert opinion. These guidelines move away from "if cholesterol is high, lower it" to a more nuanced approach, focusing on patients' risk for CV disease. This approach makes sense, given that most people would not qualify for the studies that have been conducted on cholesterol-lowering drugs (Arch Intern Med 2001;161:949-54). For patients without pre-existing heart disease, the guidelines emphasize establishing their 10 year risk using a calculator based on the Framingham data (see Essential Evidence Plus) and treating only patients with a risk level of at least 20%. Adding their own spin to this risk calculation, they suggest increasing the risk estimate by 1.5 if the patient has one first-degree relative with premature heart disease, and doubling it if they have two first-degree relatives with premature heart disease. In a much more hands-off approach, the guidelines suggest treating patients meeting with this criteria with simvastatin 40 mg and -- ! -- not checking response to therapy or increasing the dose. Adopting this approach will require quite a culture change in the U.S. For secondary prevention in patients with pre-existing heart disease, the guidelines suggest starting with simvastatin 40 mg daily and increasing the dose if the patient's total cholesterol does not decrease to < 155 mg/dl (4.0 mmol/l) or low density lipoprotein <77 mg/dl (2.0 mmol/l). The guidelines suggest these approaches for men and women, even though cholesterol lowering has not been shown to be decrease mortality in women (JAMA. 2004;291:2243-2252, Lancet 2007; 369: 168-169).

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