Cholesterol awareness month: Driving further, faster
Why cholesterol?
Cardiovascular disease (CVD) is the leading cause of death worldwide, and a major driver of death, disability and health inequalities here in the UK.
High cholesterol was highlighted as a priority in the NHS Long Term Plan as one of the three ‘A-B-C’ conditions (atrial fibrillation, blood pressure and cholesterol) which are the major underlying risk factors for CVD.
It is well established that raised cholesterol is associated with an increased risk of heart disease and stroke – with a third of all ischaemic disease being associated with higher cholesterol levels.
In England, high cholesterol leads to over 7% of all deaths and affects up to 60% of adults.¹
The identification of people with, or at risk of developing, CVD is essential to allow timely intervention to reduce their cholesterol level and minimise their risk of heart attack or stroke.
Statins first
Statins have been well established as first line therapies for people diagnosed with, or at risk of CVD for more than three decades.
Over time, clinical trials have demonstrated that high intensity statins, which can lower cholesterol by up to 55%, are more effective at preventing cardiovascular events than low or moderate intensity statins.
In people with established CVD, a high-dose high intensity statin is recommended by NICE to deliver the greatest reductions in cholesterol levels and hence have the biggest impact on the risk of death, heart attack and stroke.
Earlier this year, the NHS set our national objective to increase the uptake of lipid lowering therapies in people at risk of CVD during 2023/24 and measures have been incorporated into the GP contractual framework to further expand the use of statins first line in people with diagnosed with CVD.
Despite common perceptions, statins are well tolerated in most cases – evidence suggests less than one in 10 people are intolerant to statins.
Patients should be reassured that statins are safe and effective in reducing their risk of a cardiovascular event and that, where side effects happen, alternatives are available.
Intensifying therapies
For a proportion of people, achieving the required cholesterol reduction will not be achieved with statins alone. In addition, some people cannot take statins at adequate doses or at all, due to contra-indications or adverse effects.
Further therapies will therefore be required, as an add on to statins, or as an alternative where statins are unsuitable or not tolerated.
NICE has laid out the specific role of additional lipid lowering therapies in a series of technology appraisals for ezetimibe, bempedoic acid, inclisiran and the PCSK9imabs, alirocumab or evolocumab; these are summarised in the NHS England/Accelerated Access Collaborative Summary of National Guidance for Lipid Management for Primary and Secondary Prevention of CVD.
A simplified version of the secondary prevention lipid modification pathway has been developed to support implementation.
Early identification and intensification for patients who are not achieving adequate cholesterol control will significantly reduce cardiovascular events.
Addressing global CVD risk
In order to deliver the best possible outcomes for people with or at risk of CVD it is important that, alongside lipid lowering, we identify and address other risk factors.
Behavioural change is essential where there are lifestyle factors such as smoking, increased body weight, poor diet, lack of physical activity and excess alcohol consumption.
The importance of this element of holistic care has been increasingly recognised in primary care and community settings.
Alongside lifestyle support, people with raised blood pressure, raised blood sugar and/or atrial fibrillation may need additional medical interventions to reduce their CVD risk, such as anti-hypertensive therapies, antidiabetic medicines and anticoagulants respectively.
In introducing any of these therapies, including lipid lowering, it is important to support the patient in a shared decision regarding their treatment options.
What’s the opportunity?
Improving cholesterol management presents a huge opportunity to save lives, prevent disability and reduce health inequalities.
Modelling from UCLPartners Size of the Prize indicates that if 90% of people with CVD were treated with statins, almost 14,000 heart attacks, strokes and deaths would be prevented in 3 years. If treatment rates were increased to 95%, around 22,000 events would be prevented.²
We can collectively capitalise on this opportunity by:
- Taking steps to ensure that everyone who would benefit from lipids optimisation is identified and offered appropriate treatment
- Actively raising awareness of a statins first approach to reduce cardiovascular events
- Intensifying therapy early with additional lipid lowering therapies, where statins alone have not achieved treatment targets
- Empowering patients through shared decision-making conversations to improve adherence.
² https://uclpartners.com/project/size-of-the-prize-for-preventing-heart-attacks-and-strokes-at-scale/
Dr Shahed Ahmad
Shahed Ahmad, National Clinical Director for Cardiovascular Disease Prevention at NHS England.
Dr Shahed Ahmad is an NHS England Medical Director in the South East Region where he is the Responsible Officer for over 3000 GPs. Shahed was educated at Corpus Christi College, Cambridge and University College and Middlesex School of Medicine. Shahed did his MSc in Public Health at the London School of Hygiene and Tropical Medicine and his leadership training at the London Business School. Before working for NHS England and NHS Improvement, Shahed was a Director of Public Health and led on cardiovascular risk reduction in a number of boroughs. Since joining NHS England, Shahed developed the NHS@2030 programme for GPs in South Central (a number of whom are now clinical directors of primary care networks) and developed the Hampshire Thames Valley Leadership Forum.
Helen Williams
Helen is National Clinical Director for Cardiovascular Disease Prevention at NHS England, and Clinical Care Professional Lead for Long-Term Conditions for the South East London Integrated Care System.
Helen has worked as a CVD specialist for more than 25 years across secondary, community and primary care settings. She was clinical adviser to the AHSN national atrial fibrillation (AF) programme and developed the pharmacist-led virtual clinic model to optimise uptake of anticoagulation in AF, which has now been spread nationally.
Most recently, as the National Specialty Adviser for CVD Prevention at NHS England, she worked on the delivery of the national CVD ambitions for AF, blood pressure and cholesterol in the NHS Long Term Plan.
Helen also works at UCL Partners on the implementation of Proactive Care Frameworks and CVDACTION to support primary care with the tools and resources to optimise patient outcomes, particularly for AF, blood pressure, lipids, heart failure, diabetes and chronic kidney disease.