NICE NG238 2023: CVD risk assessment and lipid modification

Who it applies to

Adults being assessed for primary prevention of cardiovascular disease, and adults with established cardiovascular disease (secondary prevention), in primary and secondary care.

Key recommendations

• Use a validated risk assessment tool (such as QRISK) to estimate 10-year cardiovascular risk in people without known cardiovascular disease, and offer atorvastatin 20 mg for primary prevention when risk is 10% or more.
• Offer lifestyle advice on diet, physical activity, alcohol, weight and smoking cessation alongside, not instead of, drug treatment where indicated.
• For secondary prevention in people with established cardiovascular disease, offer atorvastatin 80 mg, using a lower dose if there is potential for drug interactions, high risk of adverse effects, or patient preference.
• Measure a full lipid profile and for secondary prevention aim for an LDL cholesterol of 2.0 mmol/L or less, or non-HDL cholesterol of 2.6 mmol/L or less, when assessing response to treatment.
• Do not routinely stop statins because of age, and continue to consider statins in older adults, taking into account comorbidity and polypharmacy.
• If cholesterol targets are not met on maximal tolerated statin, consider adding ezetimibe before considering other non-statin therapies.
• Consider PCSK9 inhibitors for selected patients with persistently high cholesterol despite statin and ezetimibe, in line with relevant technology appraisal criteria.
• Discuss statin intolerance with patients, distinguish true intolerance from nocebo effects, and consider strategies such as dose reduction, alternate-day dosing, or switching statins before abandoning statin therapy altogether.
• Arrange structured medication review and repeat lipid testing after starting or changing lipid-lowering therapy to assess response and adherence.
• Do not use coronary artery calcium scoring to estimate cardiovascular disease risk.

What is new in this edition

• The December 2023 update reintroduced absolute treatment targets for secondary prevention, aiming for LDL cholesterol of 2.0 mmol/L or less, or non-HDL cholesterol of 2.6 mmol/L or less.
• Updated guidance clarifies management pathways for statin intolerance, encouraging a stepwise approach rather than early abandonment.
• Clarified positioning of ezetimibe and PCSK9 inhibitors within the treatment escalation pathway for both primary and secondary prevention.

Practice points for students

• QRISK score of 10% or more over 10 years is the usual threshold for offering a statin in primary prevention.
• Atorvastatin 20 mg is the standard starting dose for primary prevention, and atorvastatin 80 mg for secondary prevention.
• For secondary prevention, an LDL cholesterol of 2.0 mmol/L or less, or non-HDL cholesterol of 2.6 mmol/L or less, is the target to aim for.
• Statin intolerance is often overestimated; most patients who report muscle symptoms can tolerate a statin after a structured rechallenge.
• Lifestyle measures should always accompany, not replace, pharmacological treatment.

Condition

Other guidelines on this topic

• 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice GuidelinesAHA/ACC2026Official guideline
• The '10 commandments' for the 2025 focused update of the 2019 ESC/EAS guidelines for the management of dyslipidaemiasESC2026Official guideline

Independent educational summary written by the WhiteCoat Pro editorial team with AI assistance and checked by a second AI model. It does not reproduce the guideline text, tables or figures, and it is not affiliated with or endorsed by NICE. It is not medical advice: always read the original guideline before applying it to patients.