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← Cardiology indexChapter sections
Role and principlesAssessment and patient selectionBaseline assessmentInterventionsMedicines and treatment safetyTargets, monitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Cardiovascular risk assessment and primary prevention

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull

Role and principles

Apply NICE cardiovascular-risk assessment and lipid-modification recommendations in UK adults without established cardiovascular disease.

Risk assessment is a structured conversation, not a threshold alone. Record smoking, blood pressure, lipids, glycaemic status, kidney disease, medicines, family history and conditions that may make a calculator underestimate risk.

Optimise smoking, diet, activity, weight, alcohol, blood pressure and diabetes care alongside lipid lowering. Explain absolute benefits and harms and document the person's decision.

Key points

  • Use QRISK3 for formal 10-year risk estimation in eligible adults aged 25 to 84 years.
  • Do not use a risk calculator when risk is already high because of established CVD, type 1 diabetes, CKD with eGFR below 60 mL/min/1.73 m² or albuminuria, familial hypercholesterolaemia, or another inherited lipid disorder.
  • Offer atorvastatin 20 mg daily for primary prevention when QRISK3 is 10% or more after an informed discussion.
  • A score below 10% does not exclude atorvastatin when the person prefers treatment or risk may be underestimated.
  • For people aged 85 years or older, consider atorvastatin 20 mg without relying on a 10-year calculator; frailty, comorbidity, polypharmacy and life expectancy matter.
  • Aim for a reduction in non-HDL cholesterol greater than 40% from baseline in primary prevention.
  • Do not routinely offer aspirin for primary prevention of CVD.

Assessment and patient selection

Eligible for QRISK3

Adults aged 25 to 84 years without established CVD or a condition that already confers high risk.

Risk may be underestimated

Consider HIV treatment, severe mental illness, systemic inflammatory disease, medicines causing dyslipidaemia, obesity, deprivation and a strong premature family history.

Possible familial hypercholesterolaemia

Markedly raised cholesterol, tendon xanthomata or premature coronary disease in first-degree relatives should trigger an FH pathway rather than reassurance from QRISK3.

Secondary cause

Hypothyroidism, uncontrolled diabetes, excess alcohol, nephrotic syndrome, liver disease and relevant medicines may contribute to dyslipidaemia.

Immediate clinical diseaseRed flag

Exertional chest pain, focal neurological symptoms, acute limb ischaemia or heart-failure features require diagnostic assessment, not a primary-prevention calculator.

Baseline assessment

  1. 01
    Non-fasting full lipid profileFirst step
    Why
    Establish total, HDL, non-HDL, LDL cholesterol and triglycerides.
    Interpretation and limitations
    Repeat a fasting sample if triglycerides are markedly raised; severe or unexplained dyslipidaemia needs secondary-cause and FH assessment.
  2. 02
    Blood pressure
    Why
    Identify a major modifiable risk factor and provide QRISK3 input.
    Interpretation and limitations
    Confirm suspected hypertension using the NICE hypertension pathway rather than a single clinic value.
  3. 03
    HbA1c or glucose
    Why
    Detect diabetes or non-diabetic hyperglycaemia.
    Interpretation and limitations
    Diabetes changes both risk and management; diagnose using national criteria.
  4. 04
    Renal, liver and thyroid assessment
    Why
    Find CKD, contraindications, interactions and secondary dyslipidaemia before treatment.
    Interpretation and limitations
    Use eGFR and albuminuria to identify CKD; transaminases below 3 times the upper limit of normal do not routinely exclude a statin.
  5. 05
    QRISK3
    Why
    Estimate 10-year CVD risk in eligible adults.
    Interpretation and limitations

Interventions

01FirstStructured primary-prevention assessmentFirst stepAdult without known CVD attends for prevention review or NHS Health Check.+
  1. 1Confirm that this is primary prevention and identify conditions in which QRISK3 should not be used.
  2. 2Measure smoking status, blood pressure, BMI, full lipids, glycaemic status and renal function; review family history, comorbidity and medicines.
  3. 3Calculate QRISK3 when eligible and discuss absolute risk, uncertainty and modifiable contributors.
  4. 4Address lifestyle and condition-specific treatment; arrange timely review rather than waiting indefinitely before treating high risk.
02NextStart and assess lipid loweringQRISK3 is 10% or more, risk is otherwise high, or treatment is chosen after informed discussion.+
  1. 1Treat important secondary causes and check contraindications, interactions, baseline lipids and liver transaminases.

Medicines and treatment safety

First-line lipid lowering when NICE criteria and informed choice support treatment.

Atorvastatin

20 mg orally once daily for primary prevention.

Check interactions, pregnancy status and liver disease; investigate unexplained muscle symptoms and use a lower dose or alternative strategy if intolerance is confirmed.

NICE-recommended option when a statin is contraindicated or not tolerated, or as add-on therapy when the lipid response remains inadequate.

Ezetimibe

10 mg orally once daily.

Check hepatic impairment and interactions; when combined with a statin, retain statin safety monitoring.

Targets, monitoring and follow-up

  • Repeat full lipid profile and liver transaminases 2 to 3 months after starting or changing lipid-lowering treatment.
  • For primary prevention, compare non-HDL cholesterol with baseline and aim for a reduction greater than 40%.
  • Measure liver transaminases again at 12 months; further routine testing is unnecessary unless clinically indicated.
  • Ask about adherence, muscle symptoms, new medicines, pregnancy plans and lifestyle change at each review.
  • Recalculate or revisit cardiovascular risk when circumstances change; do not use falling cholesterol on treatment to imply untreated baseline risk was low.

Special situations

Risk is not a diagnosis

QRISK3 estimates probability in people without established disease; it must not delay assessment of symptoms suggesting current CVD.

Below threshold can still merit treatment

NICE explicitly allows atorvastatin below 10% when informed preference or underestimated risk justifies it.

CKD bypasses QRISK3

eGFR below 60 mL/min/1.73 m² or albuminuria places the person on the CKD lipid pathway.

Non-HDL is practical

It is calculated from a non-fasting profile and is the NICE treatment-response measure for primary prevention.

Aspirin is different

Lipid lowering can prevent first events without the bleeding trade-off that makes routine aspirin unsuitable for primary prevention.

Common pitfalls

  1. 01

    Using QRISK3 in established CVD, type 1 diabetes, significant CKD or familial hypercholesterolaemia.

  2. 02

    Treating 10% as a rigid permission boundary rather than part of shared decision-making.

  3. 03

    Starting aspirin routinely for primary prevention.

  4. 04

    Attributing every muscle symptom to statins without dechallenge, review and alternative causes.

  5. 05

    Failing to check response and adherence 2 to 3 months after starting treatment.

Practice

Two practice questions

Your practice draft is saved in this browser.

Question 1 of 2
0 correct
CardiologyOriginal SBA

Choosing primary-prevention treatment

A 58-year-old non-smoking man without established CVD has a QRISK3 score of 13%. Secondary causes of dyslipidaemia have been addressed. Which is the recommended initial lipid-lowering regimen?

Choose one answer, then submit
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG238: Cardiovascular disease risk assessment and reductionCurrent UK risk assessment, statin initiation, targets and monitoring.
  • NICE CKS: CVD risk assessmentPrimary-care implementation and NHS Health Check context.
  • NICE CG71: Familial hypercholesterolaemiaFH identification and cascade testing.
  • Atorvastatin 20 mg SmPCUK product dosing and cautions.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
Ten percent or more supports an offer of atorvastatin 20 mg; interpret lower values with lifetime risk, additional risk factors and preference.
  • 2Offer atorvastatin 20 mg once daily for primary prevention.
  • 3Repeat full lipids and liver transaminases after 2 to 3 months and assess adherence and adverse effects.
  • 4Aim for greater than 40% non-HDL reduction; optimise the tolerated statin and consider NICE-recommended non-statin therapy when needed.
    • 03EscalationSevere or atypical dyslipidaemiaEscalationPossible FH, very high triglycerides, unexplained extreme values or failure despite verified adherence.+
    1. 1Repeat and confirm the result, review alcohol, diet, diabetes, thyroid, renal and liver disease and medicines.
    2. 2Use the NICE FH criteria and arrange genetic or lipid-specialist assessment when indicated.
    3. 3EscalationEscalate urgently if triglycerides are sufficiently high to create pancreatitis risk or if acute symptoms are present.
    4. 4Offer cascade testing through the national FH pathway when a pathogenic familial variant is identified.