Secondary Prevention of Coronary Heart Disease and Stroke – Lipid Management Guideline

This guideline contains brief guidance on the management of cholesterol in patients with atherosclerotic arterial disease. This includes patients who have had a previous myocardial infarction (MI), previous coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), angina, proven coronary artery disease (invasive or CT angiography), ischaemic stroke or transient ischaemic attach (TIA), or peripheral arterial disease. It also includes patients with significant coronary calcification or atherosclerosis reported on non-cardiac imaging. Further information is available in the full GGC guideline, Coronary Heart Disease and Stroke, Primary and Secondary Prevention Guidelines (Cholesterol).

Introduction

The optimal management of atherosclerotic arterial disease requires control of all risk factors including lifestyle and co-morbidities. Nonetheless, the introduction of lipid-modification therapy should not be delayed for high risk individuals whilst these measures are being addressed. High risk patients (with established atherosclerotic arterial disease) should be offered treatment with a statin regardless of total blood cholesterol concentration.

N.B. The treatment of frail or very elderly people with statins should be guided by individual circumstances and co-morbidities, and need not follow these guideline recommendations.

Therapeutic Management

See cholesterol management flowchart. Further information on the management of lifestyle modifications, co-morbidities, statin intolerance and raised triglycerides can be found below.

Management of lifestyle and co-morbidities

Relevant dietary and lifestyle advice and support should be offered where appropriate (e.g. smoking cessation, safe alcohol limits, exercise prescription and weight management).
Ensure other forms of treatment for the secondary prevention of vascular disease have been optimised (e.g. anti-platelet therapy, ACE-inhibitors, beta-blockers).
Address and optimise the management of other relevant comorbidities as appropriate (e.g. treatment of left-ventricular systolic dysfunction (LVSD) or atrial fibrillation (AF), blood pressure control in hypertension, glycaemic control in diabetes).

Statin intolerance

The majority of side-effects attributed to statins are due to an expectation of side effects ("nocebo effect"), rather than an adverse effect of the medication. The evidence for improved cardiovascular outcomes with the use of statins is very strong, so it is important to ensure that there is genuine intolerance before considering an alternative.

Check Creatine Kinase (CK) if the patient complains of myalgia to exclude rhabdomyolysis.
Check for drug interactions (Athens login required) which might increase exposure to atorvastatin.
If patients are intolerant to atorvastatin 80mg, consider reducing the dose or switching to an alternative. If necessary combine a lower dose of statin with ezetimibe.
If patients are genuinely intolerant to all statins, then prescribe ezetimibe oral 10mg daily as monotherapy (off-label indication- accepted for use on the NHSGGC Adult Formulary).

Fibrates, anion exchange resins, and omega-3 preparations are not routinely recommended as alternative to statins except on specialist advice. If the patient is intolerant to more than three statins and ezetimibe for secondary prevention, then consider referral to the Lipid Clinic.

Advice on raised triglycerides

Triglycerides are measured routinely as part of a full lipid profile. Elevated triglyceride levels on a random sample may simply be due to the presence of dietary triglycerides, so a fasting sample should be obtained if elevated. Persistently raised triglycerides are commonly due to secondary causes (e.g. obesity, diabetes, alcohol excess, medicines) which should be identified and managed, then a further fasting sample arranged.

Lipid Clinic Referrals

Indications for referral include:

Patients with known or suspected familial hypercholesterolemia (e.g. patients with persistently high fasting triglycerides and a family history of premature ischaemic heart disease or pancreatitis).
Failure to meet cholesterol targets in patients with atherosclerotic arterial disease.
Intolerance to multiple statins (and ezetimibe) in patients with atherosclerotic arterial disease.
Patients with markedly raised triglycerides after management of secondary causes (routine referral if >10mmol/L, urgent referral if >20mmol/L).

Guideline reviewed: August 2022

Page last updated: November 2022