• Offer lipid modification therapy to adults with cardiovascular disease (e.g. people with a past or current history of myocardial infarction, angina, stroke, transient ischaemic attack, or peripheral arterial disease).

In depth

• Manage other modifiable risk factors, such as smoking, high blood pressure, and obesity.
• Manage secondary causes of dyslipidaemia (e.g. hypothyroidism).
• Prescribe appropriate antiplatelet treatment.
• Provide lifestyle and dietary advice such as increased physical activity, reduction of alcohol consumption, and adoption of a cardioprotective diet.
• For further information, see the CKS topic on CVD risk assessment and management.

In depth

• Perform the following tests (if not already done as part of the cardiovascular risk assessment):
• Two lipid measurements (with one measurement based on a fasting sample).
• A liver function test.
• Fasting blood glucose.
• Renal function.
• Creatine kinase, if the person is at high risk of experiencing muscle toxicity.
• Serum thyroid stimulating hormone (if dyslipidaemia is present).

In depth

• Prescribe a statin, unless this is contraindicated.
• 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 simvastatin 40 mg is contraindicated.
• Higher intensity statin therapy (simvastatin 80 mg or atorvastatin 80 mg) should only be considered first-line for people with acute coronary syndrome. Treatment should be initiated in secondary care.

In depth

• Repeat lipid measurement:
• For people with acute coronary syndrome:
• Perform a fasting lipid measurement around 3 months after initiating statin therapy.
• For all other people taking a statin or other lipid-modifying drugs for secondary prevention:
• Check lipid profile around 8 (+/– 4) weeks after initiation, and after each adjustment to treatment.
• Lipid profile should be reviewed annually once the individual has reached an optimal, achievable target.
• For people taking statins, recheck liver function tests (LFTs) within 3 months of starting treatment and again at 12 months.
• If they develop unexplained muscle symptoms (pain, tenderness, weakness):
• Check creatine kinase (CK).
• Stop the lipid-modifying drug immediately if muscle symptoms are severe or if CK is five times or more the upper limit of normal.
• Note: people should be advised to seek medical advice and to stop the lipid-modifying drug if they develop unexplained muscle symptoms.
• Discontinue the statin and seek specialist advice if they develop unexplained peripheral neuropathy or presenting features of interstitial lung disease.

In depth

• Consider offering a fibrate, modified-release nicotinic acid or a bile acid sequestrant.
• Evidence supporting the use of these drugs for secondary prevention is poor compared to statins.
• The decision to select a particular lipid-modifying drug should take into account patient preference and tolerability, comorbidities, multiple drug therapy, and the benefits and risks of treatment.

In depth

• Consider higher intensity lipid modification therapy if total cholesterol of less than 4 mmol/L or low-density lipoprotein cholesterol of less than 2 mmol/L has not been achieved.
• Any decision to offer a higher intensity statin should take into account patient preference and tolerability, comorbidities, multiple drug therapy, and the benefits and risks of treatment.
• A target total cholesterol level of less than 5 mmol/L should be used as the minimum standard of care for all people with cardiovascular disease. Wherever possible, the optimal treatment targets should be achieved.

In depth

• For people already taking simvastatin 40 mg daily: increase the dose to simvastatin 80 mg daily if tolerated.
• For people already taking pravastatin 40 mg, or less than simvastatin 40 mg daily:
• If there are no contraindications or tolerance issues to simvastatin 40 mg, consider increasing to, or changing to, simvastatin 40 mg.
• If targets are still not met with simvastatin 40 mg daily, increase to simvastatin 80 mg if tolerated.
• For people initiated with a non-statin lipid-modifying drug (i.e. a statin is not suitable):
• Consider increasing the dose of the initial drug to its maximum licensed or tolerated dose.
• If this is ineffective, consider adding a second lipid-modifying drug from a different class (other than a statin).

In depth

• Refer people with suspected familial hypercholesterolaemia (FH) or other monogenic familial disorders for specialist management.
• Consider seeking specialist advice in managing people with e.g. complex lipid disorders, multiple drug intolerance.

In depth