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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Dyslipidaemia and familial hypercholesterolaemia

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

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Synopsis

Translate lipid results into UK primary- and secondary-prevention treatment, recognise familial hypercholesterolaemia and intensify therapy safely to national targets.

  • Offer atorvastatin 20 mg for primary prevention when QRISK3 10-year CVD risk is at least 10%; do not deny treatment solely because risk is below 10% when informed preference or underestimated risk supports it.
  • For established CVD, offer atorvastatin 80 mg unless interactions, adverse-effect risk or patient preference justify a lower dose.
  • Aim for more than a 40% reduction in non-HDL cholesterol in primary prevention and LDL cholesterol 2.0 mmol/L or less or non-HDL cholesterol 2.6 mmol/L or less in secondary prevention.
  • Measure a full lipid profile and ALT/AST at baseline; recheck lipids and transaminases 2–3 months after starting or changing lipid-lowering treatment.
  • Do not measure CK routinely: check it before treatment only with unexplained muscle symptoms and measure it if such symptoms develop on therapy.
  • Suspect familial hypercholesterolaemia from marked untreated cholesterol, premature coronary disease, tendon xanthomata or family history; do not use QRISK to decide treatment in FH.
  • Adults with FH need a high-intensity statin aiming for at least a 50% LDL reduction from baseline, specialist assessment when criteria are met and DNA-based cascade testing of relatives after an index mutation is found.
  • Severe triglycerides need a separate pathway: triglycerides above 20 mmol/L require urgent specialist review because pancreatitis risk is substantial.

Key red flags

Severe hypertriglyceridaemia

Triglycerides above 20 mmol/L, or 10–20 mmol/L persisting on a fasting repeat, may reflect uncontrolled diabetes, alcohol, medicines or a genetic disorder and carries pancreatitis risk.

Investigation priorities

01
Full lipid profileFirst step

Quantify total, HDL, non-HDL and triglycerides and calculate LDL where valid.

Management branches

primary preventionNo established CVD

A lipid profile and cardiovascular risk review identify a prevention opportunity.

  1. First: optimise smoking, diet, activity, weight, alcohol and blood pressure, and correct major secondary causes; do not make lifestyle change a prerequisite for statin discussion.
  2. Next: calculate QRISK3 where appropriate and offer atorvastatin 20 mg when risk is at least 10%, also considering treatment below 10% when risk may be underestimated or the informed patient prefers it.
  3. Next: repeat full lipids and ALT/AST after 2–3 months; seek more than a 40% non-HDL reduction and check adherence/timing/secondary causes before increasing intensity.
  4. Escalation: use a higher dose/intensity if needed and tolerated, or add ezetimibe when the goal is not achieved on maximum tolerated statin treatment.

Key medicines

AtorvastatinPrimary prevention: 20 mg orally once daily. Secondary prevention: 80 mg orally once daily; use a lower dose when interactions, high adverse-effect risk or patient preference require it.Contraindicated in active liver disease and during pregnancy/breastfeeding. Review CYP3A4 interactions including some macrolides, azoles, antivirals and ciclosporin; muscle risk rises with interacting drugs. Stop and urgently assess suspected rhabdomyolysis.
Ezetimibe10 mg orally once daily, with or without food.Check liver tests when combined with a statin according to the statin regimen. Review unexplained muscle symptoms and avoid in pregnancy when given with a statin; ciclosporin can increase exposure.
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Sources and review status6 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 lipid modificationPrimary/secondary statin doses, lipid targets, safety tests and escalation.
  • NICE CG71: Familial hypercholesterolaemia—identification and managementCase finding, Simon Broome/DLCN, statin response and cascade testing.
  • eMC: Atorvastatin SmPCDose, contraindications, interactions and muscle/liver safety.
  • eMC: Ezetimibe 10 mg SmPCStandard dose and combination safety.
  • NICE TA694: Bempedoic acid with ezetimibeEligibility when statins cannot be used and ezetimibe alone is inadequate.
  • NICE TA733: Inclisiran for primary hypercholesterolaemia or mixed dyslipidaemiaSecondary-prevention event and LDL eligibility criteria.

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

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom