New lipid targets at odds with international standards

Once again, NICE guidance appears to be driven by economic considerations rather than clinical evidence, leaving it out of step with other established guidelines – and even with Quality and Outcomes Framework goals

It is worth reading the latest NICE guideline on Cardiovascular disease: risk assessment and reduction, including lipid modification (NG238),¹ as much of the work of general practice nurses will involve some aspect of CVD prevention, whether supporting with lifestyle changes or prescribing, titrating and monitoring medication.

However, there is one section which has caused a great deal of discussion with my colleagues within the Primary Care Cardiovascular Society (PCCS),2 and that is the recommendations for lipid management, specifically the targets that NICE has set. It’s fair to say that NICE advice is often at odds with other guidelines (see asthma, for example) and on this occasion, there is real concern that the focus on cost is at the expense (literally) of reducing cardiovascular events in an evidence-based way. HEART UK³ has referred to this in its response to the guideline, at https://www.heartuk.org.uk/news/latest/post/201-heart-uk-response-to-nice-guidance-december-2023

It is important to recognise the difference between recommendations for people at risk of CVD (a score of 10% or more using QRisk3 – see qrisk.org) versus those with an established diagnosis of CVD. In primary prevention, NICE continues to recommend a reduction in non-HDL cholesterol of 40%. This is a clunky target for people to work out, assuming they have access to pre-treatment levels, and a 40% reduction may not be enough to reduce risk in those at the top end of the primary prevention risk spectrum. HEART UK notes that the only medications that have been shown to lead to a 40% reduction are atorvastatin 20mg or higher, rosuvastatin 10mg or higher, or any combination of atorvastatin and ezetimibe, so GPNs should be mindful of this when recommending, prescribing or reviewing medication.

In those with established CVD, NICE recommends an LDL cholesterol target of 2.0 mmol/l or lower and/or a non-HDL cholesterol target of 2.6 mmol/l or lower. These targets are higher than other UK targets, such as QOF, where the recommendation is to get LDL cholesterol below 1.8 mmol/l or non-HDL cholesterol to below 2.6 mmol/l.

The NICE targets are also higher than international guidelines including those from the European Society of Cardiology (ESC) and the American Heart Association (AHA), both of which recommend LDL cholesterol targets of below 1.8 mmol/l and ideally below 1.4 mmol/l.^4,5 The NHS lipid lowering pathways also recommend an LDL cholesterol below <1.8 mmol/l.

NICE has taken a more proactive approach to the use of ezetimibe, however, stating that this should be prescribed to help people reach targets levels and also for people at target, because of the evidence that lower is better. This seems to be at odds with their approach to target setting.

As HEART UK states, these new targets are likely to cause confusion for clinicians and patients alike. Changing the goal posts and quoting different targets based on cost rather than clinical evidence, is not going to help people get a firm grip on the subject of lipid management. To keep it simple, all the evidence suggests that when it comes to lipids, the lower the better.

REFERENCES

1. NICE NG238. Cardiovascular disease: risk assessment and reduction, including lipid modification; December 2023 https://www.nice.org.uk/guidance/ng238

2. Primary Care Cardiovascular Society www.pccsuk.org

3. Heart UK. Response to NICE guidance; 14 December 2023 https://www.heartuk.org.uk/news/latest/post/201-heart-uk-response-to-nice-guidance-december-2023

4. European Society for Cardiology (ESC) 2019 Guidelines on Dyslipidaemias (Management of); August 2019. https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Dyslipidaemias-Management-of

5. American Heart Association (AHA) 2023 Guideline for the Management of Patients With Chronic Coronary Disease; 20 July 2023 https://www.ahajournals.org/doi/10.1161/CIR.0000000000001168