Print Print
CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.

Lipid modification - primary and secondary CVD prevention - Management
Which first-line lipid modification therapy should I offer for primary prevention of cardiovascular disease?

  • Prescribe a statin, unless this is contraindicated.
    • If statin treatment is appropriate, it should be offered as soon as practicable after a full risk assessment.
    • Simvastatin 40 mg daily is the first-line choice.
    • Consider a lower dose of simvastatin or an alternative statin (e.g. pravastatin 40 mg daily) if there are potential drug interactions or if simvastatin 40 mg is contraindicated (e.g. in people with renal impairment).
  • Do not offer higher intensity statin therapy (e.g. simvastatin 80 mg daily), or a combination of a statin and other lipid-modifying treatment (including fish oil supplements), for the primary prevention of cardiovascular disease.
Basis for recommendation
  • These recommendations reflect guidance issued by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2008a] and are based on an earlier NICE Technology Appraisal on statins for the prevention of cardiovascular events [NICE, 2006].
  • Statins for primary prevention:
    • When considering lipid modification therapy in primary prevention, preference was given by NICE to drugs for which there is evidence in clinical trials of a beneficial effect on cardiovascular morbidity and mortality.
    • Statins are recommended first-line by NICE for primary prevention because there is good evidence from meta-analyses that statins are associated with a significant reduction (compared with placebo) in the risk of all-cause mortality, fatal and non-fatal myocardial infarction, stable angina, and a composite endpoint of coronary heart disease death plus non-fatal myocardial infarction.
    • The evidence for other drugs (e.g. bile acid sequestrants, ezetimibe, and fibrates) is less robust.
  • Safety of statin therapy:
    • NICE found good safety data for the use of statins.
    • Evidence from two large meta-analyses indicates that serious muscular (e.g. rhabdomyolysis, myopathy) and liver (e.g. abnormal liver function tests) adverse effects are infrequent with statin therapy.
    • Evidence from another meta-analysis (involving 86,936 participants) found statins to have a neutral effect on cancer and cancer death risks. No type of cancer was affected by statin use, and no subtype of statin affected the risk of cancer.
  • Choice of statin:
    • NICE recommends that, when the decision has been made to prescribe a statin, therapy should usually be initiated with a drug with a low acquisition cost (taking into account the required daily dose and product price per dose) [NICE, 2008a].
    • Cost effectiveness analysis undertaken by the NICE Guidance Development Group indicates both simvastatin 40 mg and pravastatin 40 mg to be cost effective options for the primary prevention of cardiovascular disease (CVD); these are considered to be the most effective preparations at the lowest acquisition cost [National Collaborating Centre for Primary Care, 2008a].
    • Where there is potential for drug interactions, pravastatin is recommended as an alternative to simvastatin because, unlike simvastatin, it is not significantly metabolized by cytochrome P450 isoenzymes.
    • Note: for pravastatin, the dose of 40 mg daily was the only studied starting and maintenance dose used in all the preventive morbidity and mortality trials [ABPI Medicines Compendium, 2005b].
  • Higher intensity statin therapy and combination therapy with statin:
    • These are not recommended because NICE found no evidence to support the clinical effectiveness of higher intensity statins (e.g. simvastatin 80 mg daily) and of combining statins with other lipid-modifying drugs (e.g. bile acid sequestrant, fibrate, nicotinic acid, or fish oil supplement) for primary prevention of CVD [National Collaborating Centre for Primary Care, 2008a].

© NHS Institute for Innovation and Improvement