Quality standard

Quality statement 2: Excluding secondary causes

Quality statement 2: Excluding secondary causes

Quality statement

Adults with a 10‑year risk of cardiovascular disease (CVD) of 10% or more are assessed for secondary causes before any offer of statin treatment.

Rationale

Several conditions can increase a person's risk of CVD, which may also cause dyslipidaemia (abnormal lipid levels). It is important that these are identified before starting statin treatment, which can cause side effects in adults with certain conditions. Common secondary causes of increased risk of CVD or dyslipidaemia include uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Structure

Evidence of local arrangements to ensure that adults with a 10‑year risk of CVD of 10% or more are assessed for secondary causes before any offer of statin treatment.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from local protocols.

Process

Proportion of adults with a 10‑year risk of CVD of 10% or more who are assessed for secondary causes before any offer of statin treatment.

Numerator – the number in the denominator who are assessed for secondary causes before any offer of statin treatment.

Denominator – the number of adults with a 10‑year risk of CVD of 10% or more.

Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.

What the quality statement means for different audiences

Service providers (primary care services) should ensure that adults with a 10‑year risk of CVD of 10% or more are assessed for secondary causes before offering statin treatment. This assessment should be recorded and made available for any monitoring requests.

Healthcare professionals (such as GPs and nurses) assess adults with a 10‑year risk of CVD of 10% or more for secondary causes before offering statin treatment.

Commissioners ensure that GPs in their locality are aware of the need for adults with a 10‑year risk of CVD of 10% or more to be assessed for secondary causes before offering statin treatment.

Adults with a 1 in 10 or more chance of developing CVD in the next 10 years (a 10‑year risk of 10% or more) are checked to see if there are any underlying causes before being offered treatment with a medicine called a statin. This will indicate whether there is another reason for their increased risk that might need a different treatment.

Definitions of terms used in this quality statement

Assessment for secondary causes

Secondary causes of increased CVD risk and dyslipidaemia include excess alcohol use, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome. An assessment for secondary causes of CVD risk or dyslipidaemia should include:

  • smoking status

  • alcohol consumption

  • blood pressure

  • body mass index or other measure of obesity

  • full lipid profile

  • diabetes status

  • renal function

  • transaminase level

  • thyroid‑stimulating hormone in people with symptoms of underactive or overactive thyroid.

[NICE's guideline on cardiovascular disease, recommendations 1.4.3 and 1.5.5]

Equality and diversity considerations

The statement includes adults with a 10‑year risk of CVD of 10% or more, as determined by their QRISK3 score if they are between 25 and 84 years. Adults aged 85 years and older should be considered to be at high risk based on age alone, particularly those who smoke or have high blood pressure. People aged under 25 are not at high risk for CVD unless they have a specific condition that increases risk.

Clinical judgement should inform interpretation of results from CVD risk tools when used in certain groups of people because tools may underestimate the risk (see NICE's guideline on cardiovascular disease, recommendation 1.1.10). When using a QRISK3 risk score to inform drug treatment decisions in these populations, particularly if it is near the threshold for treatment, take into account other factors that may predispose the person to premature CVD that may not be included in calculated risk scores.