GPAtlas🧭 When to consider lipid modification
Lipid modification should be considered in every adult, but the decision to offer a statin follows two distinct routes. A defined high-risk group is treated on clinical grounds alone, where a formal risk score is neither needed nor used. Everyone else aged 25–84 has their 10-year risk of cardiovascular disease (CVD) estimated with QRISK3, and a statin is offered at a 10-year risk of 10% or more.
The two skills in primary care are to place each patient on the correct route, and to recognise the small number of red-flag presentations – pancreatitis-level hypertriglyceridaemia and statin-induced muscle injury – that need urgent action.
| High-risk group (treat without QRISK3) | Defining criteria |
|---|---|
| Established atherosclerotic CVD (secondary prevention) | Ischaemic heart disease (IHD) or angina, previous myocardial infarction or acute coronary syndrome (ACS), ischaemic stroke or transient ischaemic attack (TIA), or peripheral arterial disease (PAD). |
| Chronic kidney disease (CKD) | Estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m² on at least 2 occasions, 3 months apart, and/or albuminuria. |
| Type 1 diabetes | Aged over 40, or diabetes duration over 10 years, or established nephropathy, or other CVD risk factors. |
| Familial hypercholesterolaemia (FH) | Clinically suspected FH, or total cholesterol > 7.5 mmol/L with a family history of premature coronary heart disease (CHD) – assess and treat per the NICE FH guideline. |
For all others aged 25–84 (including type 2 diabetes), use QRISK3 to estimate 10-year CVD risk. Offer a statin at a risk of ≥ 10%, and consider one below 10% after an informed discussion of benefits and harms. In those aged 85 and over, do not calculate a score; consider them at increased risk by age alone and decide individually, weighing frailty, comorbidity and life expectancy.
Recognise that QRISK3 may underestimate risk in HIV, systemic lupus erythematosus (SLE) and other autoimmune or inflammatory disorders, severe mental illness (SMI), people on corticosteroids or atypical antipsychotics, those recently stopped smoking, and those on immunosuppressants – apply clinical judgement and consider treating.
Source: NICE NG238
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