01Role and principlesWho benefits and the main preventive aims.
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.
02Assessment and patient selectionRisk features, eligibility and important cautions.
Adults aged 25 to 84 years without established CVD or a condition that already confers high risk.
Consider HIV treatment, severe mental illness, systemic inflammatory disease, medicines causing dyslipidaemia, obesity, deprivation and a strong premature family history.
Markedly raised cholesterol, tendon xanthomata or premature coronary disease in first-degree relatives should trigger an FH pathway rather than reassurance from QRISK3.
Hypothyroidism, uncontrolled diabetes, excess alcohol, nephrotic syndrome, liver disease and relevant medicines may contribute to dyslipidaemia.
Exertional chest pain, focal neurological symptoms, acute limb ischaemia or heart-failure features require diagnostic assessment, not a primary-prevention calculator.
03Baseline assessmentMeasurements that guide the plan and track progress.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 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.
- 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.
- 03
HbA1c or glucose - Why
- Detect diabetes or non-diabetic hyperglycaemia.
- Interpretation and limitations
- Diabetes changes both risk and management; diagnose using national criteria.
- 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.
- 05
QRISK3 - Why
- Estimate 10-year CVD risk in eligible adults.
- Interpretation and limitations
- Ten percent or more supports an offer of atorvastatin 20 mg; interpret lower values with lifetime risk, additional risk factors and preference.
04InterventionsLifestyle, treatment and escalation options.
01FirstStructured primary-prevention assessmentFirst stepAdult without known CVD attends for prevention review or NHS Health Check.+
- 1Confirm that this is primary prevention and identify conditions in which QRISK3 should not be used.
- 2Measure smoking status, blood pressure, BMI, full lipids, glycaemic status and renal function; review family history, comorbidity and medicines.
- 3Calculate QRISK3 when eligible and discuss absolute risk, uncertainty and modifiable contributors.
- 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.+
- 1Treat important secondary causes and check contraindications, interactions, baseline lipids and liver transaminases.
- 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.+
- 1Repeat and confirm the result, review alcohol, diet, diabetes, thyroid, renal and liver disease and medicines.
- 2Use the NICE FH criteria and arrange genetic or lipid-specialist assessment when indicated.
- 3EscalationEscalate urgently if triglycerides are sufficiently high to create pancreatitis risk or if acute symptoms are present.
- 4Offer cascade testing through the national FH pathway when a pathogenic familial variant is identified.
05Medicines and treatment safetyRegimens, contraindications and review points.
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.
Ezetimibe
10 mg orally once daily.Check hepatic impairment and interactions; when combined with a statin, retain statin safety monitoring.
06Targets, monitoring and follow-upResponse, safety and longer-term review.
- 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.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
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.
08Common pitfallsFrequent interpretation and management errors.
- 01
Using QRISK3 in established CVD, type 1 diabetes, significant CKD or familial hypercholesterolaemia.
- 02
Treating 10% as a rigid permission boundary rather than part of shared decision-making.
- 03
Starting aspirin routinely for primary prevention.
- 04
Attributing every muscle symptom to statins without dechallenge, review and alternative causes.
- 05
Failing to check response and adherence 2 to 3 months after starting treatment.