Secondary Prevention of Cardiovascular Disease

The link to RCHT lipid teams flow chart summarising national guidelines (NICE/ACC) on lipid management can be found here.
 

The key messages in secondary prevention are below:
 

Lipid Targets

• Aim for LDLc ≤ 2.0 mmol/L or non-HDLc ≤ 2.6 mmol/L (consistent with NICE/QOF targets)
• If baseline LDLc ≥ 4.0 mmol/L OR Familial Hypercholesterolaemia, aim for at least a 50% reduction from baseline
• Targets should be individualised using clinical judgement and shared decision-making, taking into account cardiovascular risk, comorbidities, treatment tolerability, and patient preference
• Some patients reviewed in secondary care may have been given a lower LDL-C target (e.g. < 1.8 mmol/L, < 1.4 mmol/L or < 1.0 mmol/L), in line with specialist recommendations.

Lifestyle & Risk Factor Management

• Smoking cessation, weight reduction (if required), alcohol reduction, healthy diet, 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
• Consider familial hypercholesterolaemia and Lpa if meets criteria (see lipid home page)

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

Lipid Lowering Therapy

Statins

• High intensity statin therapy remains first line treatment in secondary prevention e.g.

  • atorvastatin 80mg
    Use lower initial dose of Atorvastatin and slowly increased if tolerated if: eGFR <60ml/min, high risk of adverse effects (see statin intolerance), or patient preference

• See statin intolerance page if unable to tolerate statins

• Recheck lipids and liver function tests as per monitoring guidelines (below)

• If despite maximum tolerated statin therapy:

  •  LDLc remains above target but ≤ 2.5 mmol/L then consider:

    • Ezetimibe

    • If target is still not achieved then consider adding Bempedoic Acid (combination tablets available)
      Prescribe bempedoic acid with caution if history of gout (raises uric acid)

• Both ezetimibe and bempedoic acid can be used in combination with any other lipid therapy

• Recheck lipids and liver function tests as per monitoring guidelines below

• If despite maximum tolerated statin therapy:

  •  LDLc ≥2.6 - 4 mmol/L OR

  • LDLc 2.6 - 3.5 in very high-risk patients*
    
    Then consider:

    • Inclisiran (if not already taking a PCSK9i monoclonal antibody)

  • Recheck lipids and liver function tests as per monitoring guidelines below

Inclisiran Prescribing and Administration