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In primary prevention of ischaemic heart disease: - BHS guidelines
state however that statin treatment is also recommended for primary prevention
in people with high blood pressure who have a 10 year risk of cardiovascular disease
(CVD) of 20% (CVD risk replaces coronary heart disease (CHD) risk estimation in
the BHS guidelines to reflect the importance of stroke prevention as well as CHD
prevention. The CVD risk threshold of >= 20% is equivalent to a CHD risk of
approximately >=15% over 10 years)
However NICE (2) have not stated a cholesterol target for primary prevention:
- the NICE strategy basically defines
- statin therapy is recommended as part of the management strategy
for the primary prevention of CVD for adults who have a 20% or greater
10-year risk of developing CVD
- the suggestion is that treatment is initiated with simvastatin 40mg
per day and then there is no indication to check lipid levels again. This
seems to be based on the findings of the Heart Protection study (see linked
item)
NICE state with respect to primary prevention (2):
- statin therapy
- recommended as part
of the management strategy for the primary prevention of CVD for adults who have
a 20% or greater 10-year risk of developing CVD. This level of risk should be
estimated using an appropriate risk calculator, or by clinical assessment for
people for whom an appropriate risk calculator is not available or appropriate
(for example, older people, people with diabetes or people in high-risk ethnic
groups)
- decision whether to initiate stain therapy should be made after
an informed discussion between the responsible clinician and the person about
the risks and benefits of statin treatment, taking into account additional factors
such as comorbidities and life expectancy
- if statin treatment is appropriate,
it should be offered as soon as practicable after a full risk factor assessment
- when
the decision has been made to prescribe a statin, it is recommended that therapy
should usually be initiated with a drug with a low acquisition cost (taking into
account required daily dose and product price per dose)
- treatment for
the primary prevention of CVD should be initiated with simvastatin 40 mg. If there
are potential drug interactions, or simvastatin 40 mg is contraindicated, a lower
dose or alternative preparation such as pravastatin may be chosen
- higher
intensity statins should not routinely be offered to people for the primary prevention
of CVD
- a target for total or LDL cholesterol is not recommended for people
who are treated with a statin for primary prevention of CVD
- once a person
has been started on a statin for primary prevention, repeat lipid measurement
is unnecessary. Clinical judgement and patient preference should guide the review
of drug therapy and whether to review the lipid profile
- fibrates
for primary prevention
- fibrates should not routinely be offered for
the primary prevention of CVD. If statins are not tolerated, fibrates may be considered
- nicotinic
acid for primary prevention
- nicotinic acid should not be offered for
the primary prevention of CVD. Anion exchange resins for primary prevention
- anion
exchange resins
- should not routinely be offered for the primary prevention
of CVD. If statins are not tolerated, an anion exchange resin may be considered
- ezetimibe
- people
with primary hypercholesterolaemia should be considered for ezetimibe treatment
in line with 'Ezetimibe for the treatment of primary (heterozygous-familial and
non-familial) hypercholesterolaemia'
- combination therapy for
primary prevention
- combination of an anion exchange resin, fibrate or
nicotinic acid with a statin should not be offered for the primary prevention
of CVD
- combination of a fish oil supplement with a statin should not
be offered for the primary prevention of CVD
Reference:
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