Cardiovascular disease: risk assessment and reduction, including lipid modification

Resource impact: December 2023

The guideline update introduces a new target for lipid levels for secondary prevention of cardiovascular disease (CVD) and guidance on lipid-lowering treatments other than statins alone to achieve that target. It updates and replaces NICE guideline CG181 (published July 2014).

The Cardiovascular Disease Prevention Audit (CVDPREVENT) has 2.6 million adults in England with CVD. Of these, around 1.9 million did not achieve the current Quality and Outcomes Framework (QOF) treatment target for lipid levels for secondary prevention of CVD and therefore, are eligible for treatment escalation in line with the NICE guideline. See table 1.

Table 1 People with CVD who do not achieve treatment targets in England

CVDPREVENT data indicates that 1.9 million people do not achieve treatment target. However, Clinical Practice Research Datalink (CPRD) research database data used in the health economic model indicates that 57.7% out of a sample of 234,000 people with CVD achieve treatment targets with statin alone and the remainder would need to be escalated.

The committee was aware that NHS England had recently introduced a target as part of the QOF, which is similar to the target recommended in this guideline. The QOF indicators for primary care already incentivise GPs to deploy resources to escalate liquid-lowering therapy for adults who do not achieve treatment targets. The committee highlighted that this guideline recommendations for a specific lipid target for secondary prevention of CVD may also increase the use of lipid-lowering treatments.

The committee also highlighted that the use of ezetimibe, inclisiran and Proprotein Convertase Subtilisin/Kexin Type 9 inhibitors (PCSK9i), such as evolocumab and alirocumab, for secondary prevention of CVD is low. Also, inclisiran use has been increasing since the publication of the NICE technology appraisal guidance on inclisiran for treating primary hypercholesterolaemia or mixed dyslipidaemia.

PCSK9i are mostly prescribed in hospital, and the committee highlighted that numbers are unlikely to change significantly beyond current practice.

Increased uptake of high-intensity statins, ezetimibe and other lipid-lowering treatments would result in higher treatment costs. Potential costs would depend on the size of the eligible population, the escalation regimen used and the associated primary care capacity implications (GP appointments for reviews, treatment escalation and reviews following treatment escalation, pharmacies, and blood culture tests). However, any additional costs would be partly offset by savings from reduced CVD events and post-event health and social care associated costs.

Due to a lack of robust data on current practice, variation across organisations and services, and that bempedoic acid, inclisiran, evolocumab and alirocumab (see NICE's technology appraisal guidance on bempedoic acid, inclisiran, evolucumab and alirocumab) are available to the NHS with discounts, the size of the resource impact will need to be determined at a local level. A resource impact assessment template has been produced to help organisations to estimate costs at a local level. This is a new format template and for any queries on how to use the template, please contact: resourceimpactassessment@nice.org.uk.

 Implementing the guideline may:

• improve access to medicine for people with cardiovascular disease; this will lead to a reduction of high cholesterol levels for people with cardiovascular disease; therefore, reduced healthcare associated costs from a reduction in cardiovascular events such as stroke, myocardial infarction and coronary revascularization
• lead to more people receiving escalation therapy and being appropriately monitored for their cholesterol levels
• lead to better health outcomes and care experience
• lead to improved consistency of best practice across the country.

The ambition of the NHS Long Term Plan is to prevent up to 150,000 heart attacks, strokes and dementia cases in the next 10 years, by 2029.

Cardiology services are commissioned by integrated care boards. Providers are NHS hospital trusts, and primary care including community providers.