Primary care resource centre
If you work in Primary Care, this area will give you information and resources to help you manage your patients with altered lipid profiles. You can also download the guidance from NHS England below, to support your practice and decision-making.
LDL-C and non HDL-C: Why do we use different readings when managing lipids?
LDL-C is the main lipid risk factor for atherosclerotic cardiovascular disease (CVD) reported in clinical trials.
LDL-C is calculated by the laboratories using the Friedewald formula: total cholesterol minus HDL-C level minus (triglyceride divided by 2.2) in mmol/l.
As triglyceride levels in particular are much more affected by fasting or non fasting, this can affect the calculated LDL-C level but fasting does not significantly affect the total cholesterol or HDL-C level.
Non-HDL-C is calculated as total cholesterol minus HDL-C
So, for practical purposes non-HDL-C levels are used for lipid management in secondary prevention of CVD using non-fasting blood samples.
However, in patients who don’t meet the NICE approved Lipid Management Guidelines target of a non-HDL-C below 2.5mmol/l for secondary prevention in CVD, injectable therapies are an option. Where injectables are being considered, it is important to know the LDL-C level, hence the need for a fasting blood sample to assess eligibility for these drugs.
It is also important to check and consider the triglyceride level because if this is above 4.5mmol/l on a fasting sample then the Friedewald formula to calculate LDL-C is not valid and these patients should be discussed with a lipidologist.
In summary, if the non-HDL-C remains above 2.5mmol/l in patients with CVD and injectable therapies are being considered, do a fasting lipid profile for LDL-C. Providing the triglycerides are below 4.5mmol/l, if the LDL-C is above 2.6mmol/l, Inclisiran can be offered, if it’s above 3.5mmol/l PCSK9i, drugs can be considered.
Familial hypercholesterolaemia (FH): practical steps
FH affects around 1 in 250 people in the UK. Because it causes very high cholesterol, it can lead to premature coronary heart disease. Here are some practical steps you can take to tackle FH in your practice:
- Review all patients with a clinical diagnosis of FH.
- Have they been genetically confirmed? If not, check against diagnostic criteria and refer to your local lipid clinic for genetic testing.
- Review all patients who have ever had a total cholesterol above 9mmol/l.
- If they don't already have a diagnosis of FH, refer to your local lipid clinic after excluding secondary causes, listed below.
- Review all patients who have ever had a total cholesterol above 7.5mmol/l.
- Assess patients against diagnostic criteria after excluding secondary causes, listed below.
Read about the new pilot screening programme to identify children with FH.
Secondary causes of high cholesterol to rule out
- Anti-retroviral drugs
- Oral oestrogen
Health and other conditions
- Undiagnosed or poorly controlled Type 2 diabetes
- Chronic kidney disease
- Nephrotic syndrome
NHS Long Term Plan
The NHS Long Term Plan, launched in 2019, sets out bold ambitions to tackle cardiovascular disease.
Key elements for lipids/CVD:
- Prevent over 150,000 heart attacks and strokes within 10 years
- Find 25% of people with familial hypercholesterolaemia (FH) within 5 years
- Launch the CVD PREVENT national audit to support continuous clinical improvement
CVDPREVENT is a national primary care audit that automatically extracts routinely-held GP data covering diagnosis and management of six high-risk conditions that cause stroke, heart attack and dementia:
Atrial fibrillation (AF), High Blood Pressure, High Cholesterol, Diabetes, Non-diabetic Hyperglycaemia, Chronic Kidney Disease.
Key principles and benefits
Helps to support the ambition laid out in the NHS Long Term Plan to prevent 150,000 heart attacks and strokes over the next 10 years.
The audit asserts zero additional burden on practices.
Data on health inequalities and gaps in care will be highlighted to help support improvements in local practice.
The 2nd CVDPREVENT Annual Audit Report and Data and Improvement Tool has now been published. The CVDPREVENT audit, commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP) and funded by NHS England & NHS Improvement, aims to support professionally-led quality improvement in primary care for the prevention of cardiovascular disease (CVD) in England. The audit is delivered by the NHS Benchmarking Network, the Office for Health Improvement & Disparities (OHID) - National Cardiovascular Intelligence Network (NCVIN) team, and NHS Digital.
The Clinical Digital Resource Collaborative (CDRC) is an NHS-funded, digital resource that enables individuals and organisations to deliver gold-standard patient care efficiently.
Primary care key benefits:
Integrated digital resources for SystmOne and EMIS
Quick identification of patients who are likely to benefit from a change in clinical management
More accurate data for QOF and QASI reporting
Examples of best practice
For this section, we've pulled together some examples of best practice. If you'd like to share examples from your area, please get in touch.
West Yorkshire & Harrogate Healthy Hearts