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).
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.
See cholesterol management flowchart. Further information on the management of lifestyle modifications, co-morbidities, statin intolerance and raised triglycerides can be found below.
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.
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.
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.
Indications for referral include:
Guideline reviewed: August 2022
Page last updated: November 2022