People in England and Wales who have established cardiovascular disease should be offered drugs to reduce their cholesterol levels, and adults who display clinical evidence of CVD should be given statins, the National Institute for Health and Clinical Excellence has recommended.

In new guidance on the identification of people at risk of CVD and the use of lipid-lowering drugs to reduce this risk, NICE says that the offer of drugs for secondary prevention of CVD should not be delayed by the management of modifiable risk factors – smoking, high blood pressure and raised cholesterol.

For the primary prevention of CVD in people at high risk, all other modifiable risk factors should be considered and their management optimised if possible before offering drugs to reduce cholesterol levels, says NICE. However, it also recommends statin therapy as part of the management strategy in primary prevention of CVD in adults who have a 20% or greater 10-year risk of developing the disease. Treatment should be initiated with simvastatin 40mg but, if this is contraindicated, or there are potential drug interactions, a lower dose or alternative treatment such as pravastatin may be used, it says.

In information provided by NICE on the guidance for patients and carers, it advises them that “serious problems with statins are very rare.” However, it adds: “if statins are unsuitable for you, for example if you have certain illnesses, you may be offered another drug. These may be drugs called fibrates, nicotinic acid, anion exchange resins or ezetimibe [Merck & Co/Schering-Plough's Ezetrol].”

'Much-needed' clarity
NICE’s deputy chief executive, Dr Gillian Leng, commented that the new guidance will provide “much-needed clarity for healthcare professionals, many of whom report uncertainty in how to manage blood lipids in patients both with and without pre-existing” CVD. “As a result, the guideline should also help to reduce the current variation in prescribing lipid-modifying drugs in primary care,” she said.

CVD, which includes heart disease and stroke, is the leading cause of death in England and Wales, accounting for 124,000 or one in three of all deaths in 2005. Systematic review of CVD risk could involve more than three million people in assessment and treatment decisions, with the potential to prevention around 15,000 heart attacks and strokes every year, said Dr John Robinson, a general practitioner who chaired NICE’s development group for this guidance. “This is a major public health initiative and will be a welcome addition to the government’s vascular programme, as it ensures an efficient and equitable method of targeting treatment to those most likely to benefit,” he added.

The biggest change in clinical practice resulting from the guidance is likely to arise from its call for a systematic approach in primary care to the identification of patients at high risk of developing CVD, said NCC PC clinical director Dr Norma O’Flynn. “We are in quite a privileged position in the UK, in that there is almost universal registration of the population in general practice” with “extremely high” levels of computerisation and GP records that can be used to identify those patients most likely to be at high risk, she said. Therefore, “our approach need no longer be primarily opportunistic,” said Dr O’Flynn.

The guidance was produced by NICE with the National Collaborating Centre for Primary Care, which is based at the Royal College of General Practitioners.