Cardiovascular risk assessment and lipid modification

  • Quality standard
  • QS100
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Quality statement 5: Secondary prevention of cardiovascular disease

Quality statement

Adults with cardiovascular disease have a low-density lipoprotein (LDL) cholesterol level of 2.0 mmol per litre or less, or a non-high-density lipoprotein (non-HDL) cholesterol level of 2.6 mmol per litre or less. [new 2025]

Rationale

Management of LDL cholesterol or non-HDL cholesterol is important to reduce the risk of future cardiovascular events in adults with existing cardiovascular disease. High-intensity statins are the most clinically effective treatment option for the secondary prevention of cardiovascular disease (CVD) by reduction of lipid levels. Atorvastatin 80 mg is recommended as the preferred high-intensity statin, but other lipid-lowering treatments could be used if atorvastatin 80 mg is contraindicated, not tolerated or the target cholesterol level is not achieved. A non-HDL cholesterol target can be used if an LDL cholesterol level has not been requested or calculated.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.

Outcome

Proportion of adults with CVD in whom the last recorded LDL or non-HDL cholesterol level (measured in the preceding 12 months) is 2.0 mmol per litre or less for LDL cholesterol, or 2.6 mmol per litre or less for non-HDL cholesterol.

Numerator – the number in the denominator in whom the last recorded LDL or non-HDL cholesterol level (measured in the preceding 12 months) is 2.0 mmol per litre or less for LDL cholesterol, or 2.6 mmol per litre or less for non-HDL cholesterol.

Denominator – the number of adults with CVD.

Data source: CVDPREVENT indicator CVDP012CHOL reports the proportion of patients with GP-recorded CVD (narrow definition which includes coronary heart disease [CHD], non-haemorrhagic stroke and stroke cause not specified, transient ischaemic attack [TIA] and peripheral arterial disease), whose most recent blood cholesterol level is LDL cholesterol less than or equal to 2.0 mmol per litre or, non-HDL cholesterol less than or equal to 2.6 mmol per litre in the preceding 12 months. The indicator also reports data for inequality markers including sex, age, ethnicity, deprivation level and presence of a learning disability.

QOF indicator CHOL004 reports the percentage of patients on the QOF CHD, PAD or stroke/TIA register with the most recent cholesterol measurement in the preceding 12 months, showing as 2.0 mmol per litre or less if it was an LDL (low-density lipoprotein) cholesterol reading or 2.6 mmol per litre or less if it was a non-HDL (high-density lipoprotein) cholesterol reading.

What the quality statement means for different audiences

Service providers (for example primary care services and secondary care services) ensure that systems are in place for adults with CVD to achieve their lipid target, for example ensuring that LDL cholesterol or non-HDL cholesterol can be measured, and that lipid-lowering treatment can be offered.

Healthcare professionals (such as GPs, nurses, doctors, and specialist nurses) are aware of treatment targets for secondary prevention of CVD and offer adults with CVD treatment with atorvastatin 80 mg, or other lipid-lowering treatment if required, to achieve the target. They could use NHS England's summary of national guidance for lipid management. They discuss lifestyle change with the patient at the same time. Treatment and any changes to treatment should be made after an informed discussion between the healthcare professional and the adult with CVD. They are aware of strategies to address adverse effects of high-intensity statins if reported by the adult on a high-intensity statin and could use NHS England's statin intolerance pathway to address statin intolerance. They repeat measurement of LDL cholesterol or non-HDL cholesterol in adults with CVD after 2 to 3 months of treatment and consider escalation of treatment with alternative lipid-lowering treatment if the target is not achieved.

Commissioners ensure that they commission services in which adults with CVD have treatment to achieve their target lipid level.

Adults with CVD are aware of their target cholesterol level and receive treatment, and advice on lifestyle changes, that lower their bad cholesterol (non-high-density lipoprotein [non-HDL], which is mainly composed of low-density lipoprotein [LDL] cholesterol) to a level that reduces their chances of having a heart attack or stroke in the future after discussion with their healthcare professional.

Definitions of terms used in this quality statement

Adults with cardiovascular disease

Including coronary heart disease, ischaemic stroke or TIA (excluding a history of haemorrhagic stroke) or peripheral arterial disease. [Adapted from Quality and Outcomes Framework indicator CHOL004, NICE's indicator on cardiovascular disease prevention: secondary prevention with lipid lowering therapies and expert opinion]