Primary Prevention of Cardiovascular Disease

 

Primary prevention of cardiovascular disease targets people who do not have established CVD but are at risk of a first cardiovascular event. ¹ The link to RCHT lipid teams flow chart summarising national guidelines (NICE/ACC) on primary prevention can be found here.

The key messages from this flow chart are summarised below.

 

Lipid Target

• In primary prevention, the treatment goal is to achieve a ≥40% reduction in baseline non-HDLc (NICE)*
   

*There are different targets if Familial Hypercholesterolaemia or raised Lp(a) - see separate pathways

 

Risk Assessment

• Consider familial hypercholesterolemia, hypertriglyceridemia and Lipoprotein (a) in ALL patients who meet criteria on the lipid homepage and follow appropriate guidance if necessary

• Use QRISK3 if feasible to assess CVD risk in primary prevention. If not feasible use the QRISK2 calculators in System One and EMIS.*
  • For anyone with QRISK ≥10%:
    • Offer lifestyle advice and risk factor management first line
    • Offer lipid lowering therapy where lifestyle advice alone is ineffective or inappropriate

• Offer lifestyle advice, risk factor management AND lipid lowering therapy regardless of QRISK for high risk patients:
  • Type 1 diabetes AND one or more of:
    • Age >40 years
    • Diabetes duration >10 years
    • Established nephropathy
    • Other CVD risk factors 
  • Chronic kidney disease (CKD) with:
    • eGFR <60 mL/min/1.73 m² AND/ OR
    • Albuminuria

*Consider that CVD risk may be underestimated using QRISK in some patient groups e.g. HIV, severe mental illness, systemic inflammatory disorders, patients taking certain medications (e.g. antipsychotics, corticosteroid, immunosuppressants) or patients that have recently stopped smoking

• If ≥ 85 consider the benefits of lifestyle changes and lipid lowering therapy taking into account patient preference, comorbidities, frailty & life expectancy
• If QRISK <10% offer lifestyle advice and consider lipid lowering therapy if:
  • There are other risk factors for CVD
  • Patients want to take lipid lowering therapy and it is felt to be clinically appropriate

 

Lifestyle & Risk Factor Management

• Smoking cessation, weight reduction (if required), healthy diet (see HEART UK), reducing alcohol intake and regular exercise.
• Direct patients to HEART UK for self-assessment tools and educational resources.
• Manage secondary causes** and address other risk factors for CVD
• Check baseline Lipid Profile, HbA1c, LFTs, TFTs, eGFR, urinary ACR, Blood Pressure and BMI
   

**e.g. diabetes mellitus, excessive alcohol intake, poor diet, obesity, profound hypothyroidism, medications (e.g. thiazide diuretics, ciclosporin), nephrotic syndrome

 

Lipid Lowering Therapy

Statins remain the mainstay of lipid lowering therapy in primary prevention. Nice recommends starting with:

• Atorvastatin as per BNF:
  • Check LFTs at baseline, 8 -12 weeks after initiation or titration and then at 12 months OR if indicated due to symptoms of hepatotoxicity. Follow guidance in Liver Function Tests & Statins pathway  if transaminases abnormal
• To achieve lipid targets, use the maximum tolerated statin dose.
• If statins are contraindicated or not tolerated follow the statin intolerance pathway

Ezetimibe can be considered if maximum tolerated dose of statin therapy does not achieve non-HDLc target of at least 40% reduction OR if statins are contraindicated or not tolerated

Bempedoic acidcan be considered if statins are not tolerated AND Ezetimibe alone does not achieve non-HDLc target OR if Ezetimibe and statins are not tolerated

• If history of gout or raised uric acid use with caution. If gout develops after starting treatment then discontinue.
• Mild reversible reductions in haemoglobin have also been noted with bempedoic acid which are reversible on stopping the medication.

If both ezetimibe and bempedoic acid are tolerated and required then consider a combination tablet.

PCSK9-targeting therapies — Monoclonal antibody PCSK9 inhibitors (e.g. evolocumab, alirocumab) and the siRNA therapy Inclisiran are not routinely used in primary prevention.***

 

*** They may be considered only in cases of familial hypercholesterolaemia (FH) and are initiated by specialist lipid clinic

 

Monitoring

• Lipid profile & LFTs should be checked at:
  • baseline 
  • 8 – 12 weeks after initiation/ dose titration of lipid lowering therapy
  • annual review
• If the patients lipid target is not met, then lipid lowering therapy should be increased if feasible and tolerated
• HbA1c, eGFR, urinary ACR, Blood Pressure and BMI should be considered at baseline and at annual review

Advice & Guidance

There is a Lipid Advice & Guidance service available for complex or unclear cases  

 

Referral

Referral to lipid clinic is for primary prevention with no underlying genetic lipid disorders is generally not required

For primary prevention in patients with Familial Hypercholesterolaemia, Lpa(a) or Hypertriglyceridemia please follow appropriate guidance pages and refer if appropriate 

 

Patient information

• HEART UK - The Cholesterol Charity
• British Heart Foundation - What are statins, how do they work and their side effects?

 

References

• Primary prevention of CVD | Management | Lipid modification - CVD prevention | CKS | NICE
• England, NHS. Summary of national guidance for lipid management for primary and secondary prevention of CVD (lipid-management-pathway v6, Apr 2020).

 

Page Review Information

Review date:           17 February 2026
Next review date:    17 February 2028
Clinical editors:        Dr Jack Munro Berry – RMS GP
Contributors:           Dr Rachel Cooper – Consultant Clinical Biochemist