Cardiovascular disease (CVD) is a leading cause of premature death and disability due to the consequences of stroke, myocardial infarction and heart failure. Lipid management in England must improve to drive better CVD outcomes – every 1 mmol/L reduction in LDL-C is tied to a 22% reduction in major vascular events after 1 year. CVD is also the largest driver of inequalities in life-expectancy in England. The excess non-covid mortality currently seen is due to cardiovascular disease.
Purpose of the pathway
The following pathway for primary care clinicians has been developed to provide clear and simple guidance on how optimal lipid management may be achieved and provide an additional resource to support patient management. This pathway was updated in June 2024 to take account of NICE NG238 the Cardiovascular disease: risk assessment and reduction, including lipid modification guidance (published December 2023).
The pathway defines a high intensity statin as Atorvastatin 80 mg once daily (40 mg once daily if dose reduction considered indicated) or rosuvastatin 20 mg once daily if atorvastatin is contraindicated.
This is not a comprehensive clinical guideline setting out all clinical scenarios, nor does it seek to set out the clinical evidence base for interventions which are covered in the relevant NICE technology appraisals.
Development of the pathway
These pathways were developed in line with NICE guidance and adapted by a clinical advisory group.
The pathways are based on the Accelerated Access Collaborative lipid management pathway, as well as a primary care pathway developed by UCLPartners. The primary care pathway is supported by the broader UCLPartners Proactive Care Frameworks including comprehensive search and stratification tools and resources to support clinical care, self-management and behaviour change.
Supporting information
- Use of these pathways, including adaptation to local need, is at the discretion of clinicians. Adoption of these pathways should follow routine local clinical governance processes.
- Lipid Optimisation Pathway for Secondary Prevention in Primary Care © UCLPartners 2022, developed as part of the UCLP Proactive Care Frameworks to aid clinical practice and support education activities – it can be used and reproduced for this purpose.
Lipid optimisation pathway
Lipid optimisation pathway for secondary prevention in primary care and the community
Click here for an accessible text description of the pathway diagram
This pathway shows the decision steps and considerations that clinicians should use alongside relevant guidance for optimal lipid management. It starts with establishing a full lipid profile and conducting level checks according to national guidelines. Further steps, dependent on existing dosage levels, continue either to higher intensity statins and lifestyle measures or additional medications and therapies alongside the necessary reviews, discussions and checks. The pathway supports healthcare professionals to implement NICE and other relevant evidence in lipid management in secondary prevention.
Lipid lowering therapies
Lipid lowering therapies should be offered to all patients with established CVD (NICE):
- aim to achieve LDL-C and non-HCL-C targets as a minimum, greater reductions are encouraged
- lower targets are recommended post-acute event (please see Lipid optimisation pathway following an acute cardiovascular or peripheral disease event)
- do not de-escalate therapy except where there are issues of tolerability or drug interactions
- where an individual qualifies for injectable therapies, as per NICE technology appraisals, consider these in preference to ezetimibe to prevent lipid levels being lowered but remaining above the LDL-C target and below thresholds for initiating injectable therapies
- consider FH If TC>7.5mmol/L or LDL-C>4.9mmol/L or non-HDLC>5.9mmol/L with a personal or family history of confirmed CHD (<60 years) and no secondary causes
- this pathway aligns to NICE guidance NG238
Sources and footnotes
- NICE NG238: Cardiovascular disease: risk assessment and reduction, including lipid modification.
- Dose may be limited, for example if:
CKD: eGFR<60ml/min – recommended starting dose, atorvastatin 20mg
Drug interactions
Drug intolerance
Frailty
End of life - See statin intensity table. Use shared decision making and incorporate patient preference in treatment and care decisions.
- NICE guidance: Evolocumab, Alirocumab, Inclisiran, Bempodoic, Acid, Icosapent Ethyl.
Clinical advisory group
Our clinical advisory group was chaired by Professor Gary Ford (Chief Executive of Oxford AHSN and Consultant Stroke Physician) and Helen Williams, National Clinical Director of CVD Prevention, NHS England.
Membership included representation from the NHS England National Clinical Directors for Stroke, Heart Disease, Diabetes and Obesity, and Primary Care, alongside primary care and secondary care clinical specialists in cardiovascular disease.