Synopsis
Interpret lipid patterns in cardiovascular context, identify secondary and familial disease, and use statins and add-on therapy to evidence-based UK targets with safe monitoring.
- Use a non-fasting profile for routine assessment: total cholesterol, HDL cholesterol, non-HDL cholesterol and triglycerides, calculating LDL when analytically appropriate.
- For primary prevention, NICE recommends offering atorvastatin 20 mg when QRISK3 is 10% or more and considering it below 10% when risk may be underestimated or the person prefers treatment.
- For established cardiovascular disease, offer atorvastatin 80 mg unless interaction, adverse-effect risk or preference justifies a lower dose; do not recalculate QRISK.
- NICE aims for more than 40% reduction in non-HDL cholesterol in primary prevention after treatment starts.
- For secondary prevention, current NICE targets are LDL cholesterol 2.0 mmol/L or less, or non-HDL cholesterol 2.6 mmol/L or less.
- Check secondary causes and baseline safety: alcohol, diabetes, hypothyroidism, liver or renal disease, nephrotic syndrome, diet and medicines.
- Measure baseline liver transaminases, renal function and diabetes status; check creatine kinase before treatment only when persistent unexplained muscle symptoms are present.
- Mild stable transaminase elevation below three times the upper limit does not routinely exclude statin treatment, including in steatotic liver disease.
- Repeat lipids and liver tests two to three months after starting or changing treatment, then act on adherence, response and adverse effects rather than prescribing without feedback.
- When targets are not reached on maximally tolerated statin, add or refer for ezetimibe, inclisiran, PCSK9 therapy or bempedoic-acid pathways according to indication and current commissioning.
- Pregnancy and breastfeeding require a separate lipid-specialist plan; routine statins are stopped before conception and avoided during pregnancy under current UK product guidance.
Key red flags
Severe muscle pain or weakness, dark urine, marked CK rise, hyperkalaemia or acute kidney injury demands immediate statin cessation, hospital assessment and interaction review.
Triglycerides above 10 mmol/L, particularly above 20 or with abdominal pain, require urgent fasting confirmation, secondary-cause treatment and specialist planning for pancreatitis prevention.
Investigation priorities
Characterise atherogenic cholesterol and screen triglyceride severity conveniently.
Management branches
An adult without established cardiovascular disease is being considered for lipid lowering.
- Obtain a lipid profile, blood pressure, smoking, diabetes, renal and family history, exclude major secondary causes and calculate QRISK3 when the tool is appropriate.
- Optimise lifestyle and offer atorvastatin 20 mg when ten-year risk is at least 10%, also discussing treatment below threshold when risk may be underestimated.
- Repeat lipids and liver tests in two to three months, aiming for more than 40% non-HDL reduction and addressing adherence or intensity if response is insufficient.
Key medicines
Atorvastatin for primary preventionTake 20 mg orally once daily when NICE primary-prevention criteria and shared decision-making support treatment; increase intensity if the non-HDL response remains below target after adherence review.Avoid in pregnancy and breastfeeding; review liver disease, grapefruit intake and strong CYP3A4 interactions. Investigate significant muscle symptoms and use a lower or different statin when tolerability limits benefit.
Atorvastatin for secondary preventionTake 80 mg orally once daily for established cardiovascular disease unless interactions, adverse-effect risk or patient preference support a lower dose, then maximise the tolerated intensity.Do not delay acute vascular care for baseline lipids. Check current BNF interactions, hepatic status and reproductive plans; severe weakness, dark urine or marked CK elevation requires immediate cessation and assessment.