HEART UK response to NICE Guidance (December 2023)

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

Update published 14 December 2023

HEART UK welcomes the publication of the updated NICE Guidance on cardiovascular disease: risk assessment and reduction, including lipid modification on 14th December 2023.  
 
The guidance is for healthcare professionals and adults who are at risk of cardiovascular disease (CVD) or who have existing CVD.   
 
NICE agree that LDL cholesterol and non-HDL cholesterol levels should be reduced as much as possible in people with existing CVD. However, it is not considered by NICE to be cost effective to offer the full range of treatments to everyone with CVD.  
 
Whilst NICE suggest an LDL cholesterol target of 2.0 mmol/l or less and a non-HDL cholesterol target of 2.6mmol/l or less for people with CVD (as per section 1.7.1 in NG238), they recognise that these target measures are higher than other national and international targets.   This is because they have based their targets on cost effectiveness. 
 
We believe that changes to the targets are higher than those previously approved by NICE and higher than those used in Europe and America.  Additionally, they are higher than those currently being used in general practice in England.  This will cause confusion for clinicians and patients, particularly as NICE agreed that Ezetimbe should be considered as an add on treatment even in patients who are below the treatment target. 
 
Our interpretation of the guidance is that if you have CVD you should be aiming for the lowest achievable level of LDL cholesterol or non-HDL cholesterol.  The view of HEART UK is the lower the better.  
 
If your current levels are above the targets, talk to your doctor.  And even if your current levels are below the targets and you are not on Ezetimibe, talk to your doctor about whether this would be beneficial. 
 
In primary prevention (if you have high cholesterol and no existing CVD) NICE are recommending a greater than 40% reduction in non-HDL cholesterol lipid levels. 
 
The only medications shown to produce a 40% reduction are Atorvastatin 20mg or higher, Rosuvastatin 10mg or higher, or any combination of Atorvastatin and Ezetimibe. If you are taking lipid medication for primary prevention and not on one of these medications or combinations, and are uncertain of whether your lipid levels have come down by 40%, talk to your doctor. 
 
Familial Hypercholesterolaemia (FH)  wasn't covered in this update, but the NICE recommendation remains a 50% reduction in lipid levels. 
 
The only medications shown to produce a 50% reduction are Atorvastatin 80mg, Rosuvastatin 40mg, or any combination of Atorvastatin and Ezetimibe. If you are taking lipid medication for Familial Hypercholesterolaemia (FH) and not on one of these medications or combinations and are uncertain of whether your lipid levels have come down by 50%, talk to your doctor.