Lipid management: What primary care nurses need to know

Specialist lipid nurse Amie Cooper explains the principles of lipid management for the prevention of cardiovascular disease and advises how nurses can put these into practice in primary care

Why is lipid management important?

Cardiovascular disease (CVD) is the commonest cause of death in the UK, Europe and worldwide. The underlying process of atherosclerosis can develop in any arterial segment, starting from early childhood and persisting up to the end of life.

Increased levels of circulating blood lipids can play a crucial role in increasing the risk of ischaemic stroke and myocardial infarction (MI), which is why it’s important to offer people lipid-lowering treatments if needed. Yet historically lipid management has been inconsistent, despite it being a modifiable risk factor. Furthermore, inequalities persist in our communities and a significant proportion of CVD patients are not receiving optimal care, particularly among ethnic minority groups and those in socioeconomically disadvantaged areas.

Some genetic conditions can cause lipid levels to become very high. The most well known is Familial Hypercholesterolemia (FH), an inherited condition associated with high levels of low-density lipoprotein (LDL) cholesterol, which can lead to premature CVD. FH is believed to affect 1 in 250 people in the UK (around 220,000 individuals); yet only 8% of people thought to have it have been identified. The NHS long term plan published in 2019 set a target to find 25% of families affected. This is an ambitious target, and as healthcare professionals we need to be more aware of this and know when to refer.

When should people receive lipid lowering treatment?

Lipid lowering treatment is aimed at prevention of CVD events and is an integral part of both primary and secondary CVD prevention. People with genetic forms of dyslipidaemia like those diagnosed with FH undergo more specialised management, but with the same goal of preventing CVD events.

Primary prevention

In line with NICE guidelines, primary prevention of CVD means offering interventions to people who do not have established CVD but are at risk of a first cardiovascular event.

This includes people with various CVD risk factors, for example high blood pressure or lipids, those with type 1 or 2 diabetes, chronic kidney disease, or familial hypercholesterolemia, and people aged 85 and older. Nurses in general practice play a key role in identifying people who are at risk of CVD and offering primary prevention interventions including lifestyle advice and lipid-lowering treatments.

Secondary prevention

Secondary prevention of CVD involves treatment to reduce the risk of recurrent CVD events in people with established CVD, for example, those who have had an MI or stroke.

After being treated for their CVD event in hospital, these patients should be discharged from secondary care with appropriate treatment and education to manage their lipid levels. If necessary, they may be referred to the lipid clinic for further assessment.

Treatment is continued in primary care and the patient should have a three-month review including a repeat lipid profile and liver and kidney function tests, to assess the effectiveness of therapy, review lifestyle modifications and adjust each as needed.

How should primary care nurses assess CVD risk?

The main risk score recommended by NICE is the QRISK3 CVD risk assessment tool.

QRISK3 incorporates measures such as blood pressure, body mass index and lipid levels, as well as other details collected on a person’s GP record. A person’s QRISK3 score estimates their risk of having a CVD event, such as MI or ischaemic stroke, within the next 10 years.

Nurses should request a full non-fasting lipid profile – including total cholesterol, high-density lipoprotein (HDL) cholesterol, non-HDL cholesterol and triglycerides.

This is to:

Related Article: Supporting patients to adhere to statin therapy

Establish baseline lipid levels, and
Calculate the total cholesterol/HDL cholesterol ratio, the lipid measure which is inputted into QRISK3.

If the QRISK3 score is 10% or higher nurses should suggest lifestyle changes (such as dietary changes and exercise) and offer medication (statin treatment) to help reduce the CVD risk (see below).

Do not rule out primary prevention approaches if the QRISK3 score is less than 10%, however, if the person has an informed preference for taking a statin, or if there is concern that CVD risk may be underestimated – for example because the person is being treated for HIV, is already on medicines to treat CVD risk factors, has recently stopped smoking, or is taking medication that can increase lipid levels, such as immunosuppressant drugs.

Note that it is not necessary to calculate the QRISK3 in people considered at high risk of CVD due to existing disease, or age – including: people with type 1 diabetes; those with kidney disease; and those aged 85 or over, particularly if they smoke or have hypertension.

If someone is found to have very high lipid levels, and a personal and/or family history of premature heart disease, they may have familial hypercholesterolaemia and will need further assessments and, if confirmed, referral to a specialist.

In this context NICE defines very high lipid levels as:

Total cholesterol >7.5mmol/L and/or
LDL cholesterol >4.9mmol/L and/or
Non-HDL cholesterol >5.9mmol/L

Note that other potential secondary causes of hyperlipidaemia need to be ruled out first – including uncontrolled diabetes, obesity, excess alcohol consumption and untreated hypothyroidism. In addition, some medications can cause elevations in lipids, for example, thiazide diuretics and ciclosporin.

What are the initial management steps?

Lifestyle

Lifestyle modifications are a crucial part of both primary and secondary prevention; they can improve lipid levels along with other modifiable risk factors like blood pressure, and significantly reduce the risk of developing CVD.

NICE recommends the NHS Eat Well guide for healthier eating and physical activity (if able) of around 30 minutes over 5 days of the week, alongside weight management. Smoking cessation support should be offered along with advice to limit alcohol intake to recommended levels – no more than 14 units per week in both men and women.

Medication

If lifestyle change alone is ineffective or inappropriate, high-intensity statin treatment (atorvastatin 20mg daily) should be offered for primary prevention of CVD.

For secondary prevention, high-intensity statin treatment (atorvastatin 80mg daily) should be offered regardless of the person’s cholesterol level (if not contraindicated). Statin treatment should not be delayed, but lifestyle changes should be discussed at the same time as starting the treatment.

NHS England provides a useful flow-chart illustrating the recommended pathway for primary and secondary prevention in its summary lipid guidelines.

What are the goals of treatment?

In a person without a history of CVD disease, a normal ‘healthy’ total cholesterol is considered to be below 5.0mmol/L, non-HDL cholesterol below 4.0mmol/L and LDL cholesterol below 3.0mmol/L. In terms of HDL cholesterol (the ‘good’ cholesterol), the optimal level in women is above 1.2mmol/L, and in males above 1mmol/L.

While interventions for primary prevention are based on the overall QRISK3 score, in practice anyone with a QRISK3 above 10% will have raised lipid levels. In these patients, for primary prevention, the NICE recommended goal of treatment is a 40% or greater reduction from baseline in non-HDL cholesterol.

For secondary prevention, in people with a history of CVD disease, NICE recommends that treatment should aim to reduce LDL cholesterol levels to 2.0 mmol/L or lower, or non-HDL cholesterol levels to 2.6 mmol/L or lower.

In practice, in primary prevention we talk about non-HDL cholesterol with patients, and in secondary prevention we focus on LDL cholesterol, in both cases explaining what we are trying to achieve in line with national guidance.

In FH, the aim is to achieve a reduction in LDL cholesterol concentration of greater than 50% from baseline.

What if patients cannot tolerate their statin?

Statin intolerance is an important clinical challenge and is associated with an increased risk of CVD events. Statins can cause muscle pain, and this tends to happen in the first year of treatment. However, one study based on data from over 4 million patients demonstrated that the overall prevalence of statin intolerance is relatively low.

If you suspect statin intolerance in a patient then follow NHS England’s statin intolerance pathway.

What are the next steps if initial management fails?

If the person fails to reach goal lipid levels it’s important to check whether they are taking the statin as prescribed and what time they take it; patients may have been told that statins must be taken at night, but this is not necessary with statins such as atorvastatin and rosuvastatin and patients may prefer taking them in the morning, along with other medications they may require, which can help ensure they take it regularly. It is also important to discuss and review lifestyle and dietary changes.

Once these issues have been addressed then for primary prevention, if the person is considered high enough risk, and patients are not reaching their targets as per national guidance, nurses can try increasing their dose of statin every 2-3 months, up to a maximum of 80mg/day (for atorvastatin).

If someone fails to reach their target lipid level on atorvastatin 80mg/day, whether for primary or secondary prevention, then ezetimibe 10mg od may be added to a statin (often this can be more effective than doubling the dose of the statin in reducing non-HDL and LDL cholesterol). If this still does not achieve target, then the person should be referred to a specialist lipid clinic where the following medications may be tried.

Bempedoic acid/ezetimibe (Nustendi)

This is recommended only if:

statins are contraindicated or not tolerated and
ezetimibe alone does not control low-density lipoprotein cholesterol well enough.

Bempedoic acid/ezetimibe can also be initiated in primary care.

Injectable therapies

Inclisiran is available for secondary prevention in those who already have known CVD and have

an LDL cholesterol level of 2.6mmol/L or more, despite the maximum dose of other treatments to lower lipid levels (such as statins with or without other medicines, or other treatments when statins cannot be taken).

Inclisiran can be prescribed in primary care, although currently it is usually initiated in secondary care and then may subsequently be continued in primary care depending on local arrangements.

PCSK9 inhibitors are usually prescribed by hospital specialists, such as cardiologists or those running lipid clinics. They can be prescribed for people who are already taking statins and ezetimibe, but their cholesterol level has not yet been brought down to target. They can also be an option for people who can’t take statins or ezetimibe.

PCSK9 inhibitors have been approved for people with FH who:

do not have CVD and have LDL cholesterol above 5mmol/L despite taking medications such as statins and ezetimibe.
have known CVD and LDL cholesterol above 3.5mmol/L.

They have also been approved for people who don’t have FH but have known CVD, specifically in:

Patients considered ‘high risk’ with LDL cholesterol above 4mmol/L. ‘High risk’ means those who have a history of MI, have been in hospital with pain due to unstable angina, have had a procedure such as an angioplasty or stent, have ischaemic heart disease, a previous stroke or peripheral arterial disease (PAD).
Patients at ‘very high risk’ with LDL cholesterol above 3.5mmo/L. ‘Very high risk’ means having had multiple episodes of the above illnesses or events or extensive cardiovascular disease.

Amie Cooper is Specialist Lipid Nurse at New Cross Hospital in Wolverhampton

Sources and further reading

Gkiouleka A, Lunn A, Clark E. What works: Achieving equitable lipid management. Health Equity Evidence Centre. May 2024

NICE. Cardiovascular disease: risk assessment and reduction, including lipid modification. [NG238] 2023

NHS England. Summary of National Guidance for Lipid Management for Primary and Secondary Prevention of CVD. November 2022

NHS England. Statin intolerance pathway. January 2022

NICE. Familial Hypercholesterolemia: identification and management [CG71] 2019

Bytyci I, Penson P, Mikhailidis D et al. Prevalence of statin intolerance: a meta- analysis. Eur Heart J 2022; 43: 3213-23

Useful resources

NICE. Cardiovascular disease: risk assessment and reduction, including lipid modification. [NG238] 2023. Resources: Patient decision aids: Should I take a statin