For the introductory video on cardiovascular risk reduction and lipid modification: ·      https://youtu.be/jIhlkmOcsiI For the second video on cardiovascular risk reduction and lipid modification: ·      https://youtu.be/QyN3toBGCNU For the NICE guidance on cardiac chest pain video: ·      https://youtu.be/so97zARpmME For the NICE management of stable angina video: ·      https://youtu.be/BtWs0VHjp00  This episode makes reference to guidelines produced by the "National Institute for Health and Care Excellence" in the UK, also referred to as "NICE". Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by NICE. My name is Fernando Florido, and I am a General Practitioner in the United Kingdom. In this episode, I review the NICE guideline “Cardiovascular disease: risk assessment and reduction, including lipid modification” [NG238], published on 14 December 2023, focusing on what is relevant in Primary Care only. I cover statins for both primary and secondary prevention, assessing response to treatment, optimising therapy and what to do when statins are contraindicated or not tolerated.  If you have not already done so, I recommend my previous introductory video on the subject covering CVD risk assessment, recommendations for specialist referral and considerations before starting statin therapy. The link is shown above. For a refresher on the NICE guidance on cardiac chest pain and the management of stable angina, please refer to the corresponding episodes on this channel. The links are shown above. I am not giving medical advice; this video is intended for health care professionals; it is only my summary and my interpretation of the information consulted. You must always use your clinical judgement.   Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release] Music provided by Audio Library Plus Watch: https://youtu.be/aBGk6aJM3IU Free Download / Stream: https://alplus.io/halfway-through There is a YouTube version of this and other videos that you can access here: ·      The Practical GP YouTube Channel: https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk The resources consulted can be found here:The NICE guideline “Cardiovascular disease: risk assessment and reduction, including lipid modification” [NG238] Published: 14 December 2023 can be found here:·      https://www.nice.org.uk/guidance/ng238The online version of QRISK3 can be found here:·      https://qrisk.org/The QRISK3-lifetime tool can be found here:·      https://qrisk.org/lifetime/index.phpThe NICE guideline on familial hypercholesterolaemia can be found here:·      https://www.nice.org.uk/guidance/cg71The Simon Broome criteria for the diagnosis of familial hypercholesterolaemia can be found here:·      https://www.nice.org.uk/guidance/cg71/evidence/full-guideline-appendix-f-pdf-241917811The Dutch Lipid Clinic Network (DLCN) criteria for the diagnosis of familial hypercholesterolaemia can be found here:·      https://www.mdcalc.com/calc/3818/dutch-criteria-familial-hypercholesterolemia-fhTranscriptIf you're listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.Hello and welcome, I’m Fernando, a GP in the UK. Today, we’ll look at the NICE guideline on cardiovascular risk reduction and lipid modification, or NG238, which was published in December 2023, focusing on what is relevant in Primary Care only. In this episode we are going to cover statins for both primary and secondary prevention, assessing response to treatment, optimising therapy and what to do when statins are contraindicated or not tolerated.  If you have not already done so, I recommend that you listen to the previous introductory episode on the subject covering CV risk assessment, recommendations for specialist referral and considerations before starting statin therapy. The link is in the episode description. If you’d like a refresher on the NICE guidance on cardiac chest pain and the management of stable angina, please refer to the corresponding episodes on this channel. The links are also in the episode description. Right, let’s jump into it. We are going to start reviewing the prescribing of statins for the primary prevention of cardiovascular disease. And, before offering a statin, we will discuss the benefits of lifestyle changes and optimise the management of all other modifiable CVD risk factors if possible. Then, if lifestyle changes are not sufficient, we will offer statin treatment. Equally, before starting statins, we will treat comorbidities and secondary causes of dyslipidaemia, which include, for example, excess alcohol, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome. Is there a cholesterol target for primary prevention? And the answer is yes. For primary prevention of CVD, we should aim for a greater than 40% reduction in non-HDL cholesterol. So, who should get statins for primary prevention?Well, we will offer atorvastatin 20 mg for the primary prevention of CVD to people with and without type 2 diabetes who have a 10‑year QRISK3 score of 10% or more. However, NICE states that we should not rule out statins just because the QRISK3 score is less than 10% if there is a patient preference for taking it or there is concern that risk may be underestimated. Let’s remember that we do not estimate QRISK3 for people already with an increased CV risk, that is those aged 85 and older, people with type 1 diabetes and people with CKD. What do we do with them?Well, for those aged 85 and older, we should also consider treatment with atorvastatin 20 mg because they are at increased risk because of age alone, obviously being aware that there may factors that may make treatment inappropriateFor the second group, that is, those with type 1 diabetes, NICE makes a distinction as to when we must definitely offer a statin and when we should simply consider it. But in summary, atorvastatin 20mg daily should be considered for everyone with type 1 diabetes over the age of 18, irrespective of the duration of their diabetes. This advice is even more emphatic if: they are over 40 orthey have had diabetes for more than 10 years orthey have established nephropathy orthey have other CVD risk factors. Although it may be simpler for us to remember that all people with type 1 diabetes over the age of 18 would benefit from atorvastatin 20 mg. And for the third group, that is, for people with CKD, we will review their guidance a little later. This is because the management in CKD is the same for both primary and secondary prevention and it will be better to discuss it after we go through the recommendations for secondary prevention.So, what are the recommendations for secondary prevention of cardiovascular disease?Well, these recommendations apply to those with pre-existing cardiovascular disease both with and without type 1 and 2 diabetes. However, they do not apply to people with CKD, which we will discuss separately.What is the lipid target in secondary prevention? Well, we should aim for LDL levels of 2.0 mmol per litre or less, or non-HDL cholesterol levels of 2.6 mmol per litre or less. And to achieve this, we will offer atorvastatin 80 mg, whatever their cholesterol level, although we would offer a lower dose if:it could react with other drugsthere is a high risk of adverse effects orthe person would prefer to take a lower dose. We will discuss lifestyle changes at the same time but we should not delay statin treatment because of it. Also, in primary prevention we were advised to treat comorbidities and secondary causes of dyslipidaemia before starting statins. However, in secondary prevention, we will do this at the same time as starting statin treatment.If the person is taking the maximum tolerated dose and intensity of statin but the lipid target for secondary prevention of CVD is not met, we should consider additional lipid-lowering treatments and for this we should consider ezetimibe as well as injectables such as alirocumab, evolocumab and inclisiran, each one of which has their own NICE guidance. However, we can consider ezetimibe in addition to the maximum tolerated statin dose to reduce CVD risk further, even if the lipid target for secondary prevention of CVD is met. This is because studies have shown that the combination is effective in reducing CV events and ezetimibe is cost effective regardless of cholesterol levels.So now let’s look at our special group, people with CKD but excluding those on renal replacement therapy. For both primary and secondary prevention of cardiovascular disease in CKD we will offer atorvastatin 20 mg. If the lipid target for primary or secondary prevention of CVD is not met and eGFR is 30 ml per minute per 1.73 m2 or more, we will increase the dose of atorvastatin. However, if the eGFR is less than 30 ml per minute per 1.73 m2, we will discuss with the renal team. When it comes to optimising treatment for people on statins, for everyone else other than for people with CKD, if the lipid target for primary or secondary prevention of CVD is not met:we will reinforce adherence and lifestyle advice, and we will consider increasing the statin intensity and / or dose if the person is not currently taking the maximum tolerated dose of a high intensity statin. And let’s remember that the only doses of statins that are considered high intensity, based on the percentage reduction in LDL cholesterol they can produce are:atorvastatin: 20 mg to 80 mgrosuvastatin: 10 mg to 40 mg.Lower doses as well as the rest of the other statins will fall in the medium or low-intensity statins.If the person reports adverse effects when taking a high-intensity statin, we will discuss the following:stopping the statin and trying again when the symptoms have resolved to check if the symptoms are related to the statinchanging to a different statin in the same intensity group (for example, rosuvastatin if already receiving atorvastatin) orreducing the dose or changing to a lower-intensity statin, explaining that any statin at any dose reduces CVD risk. If statins are contraindicated or not tolerated for secondary prevention we will offer ezetimibe instead. This applies whatever the person's cholesterol level. If the person is taking ezetimibe but the lipid target for secondary prevention is not met, we should consider alternatives or additional lipid-lowering treatments such as oral bempedoic acid and injectables such as alirocumab, evolocumab and inclisiran, each one of which has their own NICE guidance. How do we assess response to treatment?Well, we should measure liver transaminase and full lipid profile at 2 to 3 months after starting or changing lipid-lowering treatment. We will then measure liver transaminase at 12 months, but not again unless clinically indicated. We should also advise people on statins to seek medical advice if they develop unexplained muscle symptoms (pain, tenderness or weakness). If this occurs, we will measure creatine kinase. If creatine kinase level is less than 5 times the upper limit of normal, we will reassure them that their symptoms are unlikely to be due to the statin and explore other possible causes. However, we will not measure creatine kinase levels in asymptomatic people who are being treated with a statin. When checking glucose or HbA1c, we will not stop statins because of an increase in blood glucose level or HbA1c. And we will remind the person to restart the statin if they stopped taking it because of drug interactions or to treat intercurrent illnesses. Patients on lipid-lowering treatment should have an annual medication review, offering an annual full lipid profile to inform discussions, encouraging adherence, lifestyle changes and addressing CVD risk factors.We should also discuss with people who are stable on a low-intensity statin or medium‑intensity statin the likely benefits and potential risks of changing to a high-intensity statin and agree whether a change is needed. Right, so we have looked at the lipid lowering treatments that can be recommended, primarily statins and ezetimibe followed by alirocumab, evolocumab, inclisiran and bempedoic acid if necessary and meeting their individual NICE guidance.On the other hand, lipid-lowering treatments that should not be recommended for primary and secondary prevention, including people with diabetes and CKD are:·      Fibrates·      Nicotinic acid·      Bile acid sequestrants and·      Omega 3 fatty acid compounds with the exception of icosapent ethyl, which has its own guidance for people with raised triglyceridesHowever, these treatments not recommended do not apply to people with familial hypercholesterolaemia, which has got its own guidance and for whom fibrates and other agents may be prescribed.And that is it, the second part of the NICE guideline on CVD risk reduction in primary care. Make sure to check the previous introductory episode if you have not already done so. As always, remember that this is not medical advice, but only my summary and my interpretation of the guidelines. You must always use your clinical judgement. Thank you for watching and goodbye. Thank you for listening and goodbye.

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