CVD risk: lipid management

Published in MedicineWise News

Date published: About this date

Clinical content may change after this date. This information is not intended as a substitute for medical advice from a qualified health professional. Health professionals should rely on their own expertise and enquiries when providing medical advice or treatment.

Key messages

  • Assess absolute cardiovascular disease risk early
  • Consider the potential benefit to the patient when choosing a statin and determining dose
  • Use ezetimibe in patients when a statin alone is inadequate or is not tolerated
  • Discuss cardiovascular risk with the patient to encourage lifestyle changes
  • Encourage long term adherence by regularly reminding patients of the benefits of lifestyle changes and lipid modifying therapy

Assess absolute cardiovascular risk early

Assess the absolute cardiovascular risk of everyone aged 45–74 years (Aboriginal and Torres Strait Islanders ≥ 35 years) without known increased risk, to identify if they could benefit from early intervention.1 Once a person has advanced atherosclerosis, drug therapy can reduce risk but not to the level of a person with minimal coronary lesions.2

Use a risk tool routinely for assessing people without cardiovascular disease

Risk tools are better than clinical judgement alone for assessing people without cardiovascular disease: they account for the combined effect of risk factors and can inform treatment decisions and motivate patients.3-6 People with cardiovascular disease or a known high risk condition (see Box 1) do not need a risk tool–based assessment.1

Use the Australian cardiovascular risk charts or web calculator (see for links) to estimate a risk score.1 Categorise risk  according to the chance of a cardiovascular event in the next 5 years: low < 10%, moderate 10% to 15%, or high > 15%.

Treat the risk score as a starting point for full assessment

Cardiovascular risk tools do not account for all risk factors and can underestimate risk for Aboriginal and Torres Strait Islanders, Maori and Pacific Islanders, people from the Indian subcontinent, and people with diabetes aged 45–60 years.1-7 Identify all risk factors (see Box 2) — if a person is from a population in which risk may be underestimated, treat the score as a minimum estimate of risk.1

Base management on the individual’s risk score and lipid levels

People at high cardiovascular risk clearly benefit from a lipid-lowering drug together with lifestyle changes.8-11 The benefits of drug treatment diminish as absolute risk decreases: lifestyle changes and regular assessment are the priority for people at low cardiovascular risk (<10% chance of an event in 5 years).12

Box 1: Known high risk conditions1

  • diabetes mellitus and age > 60 years or with microalbuminuria
  • moderate or severe chronic kidney disease
  • familial hypercholesterolaemia
  • systolic blood pressure ≥ 180 mm Hg or diastolic blood pressure ≥ 110 mm Hg
  • serum total cholesterol > 7.5 mmol/L 

Discuss cardiovascular risk to encourage lifestyle change

Adherence to lifestyle changes is often poor, even after myocardial infarction.14 People who are better informed and involved in decisions about their own care are more likely to adhere to an agreed management plan.4

Show patients their risk score and explain its meaning

Providing absolute cardiovascular risk scores, particularly when combined with education and when repeated, helps people understand their risk and can motivate them to make lifestyle changes.3
Use visual aids to enhance people’s understanding of their cardiovascular risk (e.g. Your Heart and Stroke Risk Score).4 Show patients how modifying different risk factors can affect their score (e.g. use the web-based cardiovascular disease risk calculator  to ‘compare’ different risk scenarios). Encourage patients to record and monitor their risk factors (e.g. Managing My Heart Health: At A Glance cards).

Box 2: Cardiovascular risk factors for assessment1,13

Total and HDLA cholesterol (or their ratio)B
Smoking statusB
Blood pressureB
Waist circumference and body mass index
Physical activity level
Alcohol intake (risk factor for raised BP)
Diabetes statusB
Left ventricular hypertrophy (if known)B
Socioeconomic status and mental health
Family history of early cardiovascular disease
A. High-density lipoprotein.
B. Included in risk tools that are based on the Framingham Risk Equation.

Consider the potential benefits when choosing a statin and dose

Choose statins first line when a lipid-lowering drug is required

Statins are the most effective cholesterol-lowering drugs, they reduce cardiovascular event rates and death in people at increased cardiovascular risk (with or without established disease) and are well tolerated.15

Prescribe a statin with lifestyle changes for people at increased cardiovascular risk

Prescribe drug treatment for people with: cardiovascular disease; a known high-risk condition (see page 1); diabetes and who are an Aboriginal or Torres Strait Islander; a family history of very early coronary disease; a high risk score; or a moderate risk scoreC plus either metabolic syndrome or a family history of early coronary disease.8,12 People at greatest cardiovascular risk benefit the most from a statin.9,10,16 Lifestyle changes benefit people at any level of risk.15

Treat people with cardiovascular disease intensively: aim for an LDL target of < 2  mmol/L

Start people with stable cardiovascular disease on a statin dose that has a moderate LDLD cholesterol–lowering effectE (e.g. simvastatin 40 mg), then treat to an LDL cholesterol target < 2 mmol/L.4,7 Consider starting people with acute coronary syndrome on a statin dose that has a greater LDL-lowering effect (e.g. atorvastatin 80 mg).4 Use the target LDL cholesterol level as a guide4 — intensive LDL lowering is beneficial for people with cardiovascular disease even if the target cannot be met.18,19
Monitor closely for muscle effects and liver enzyme elevations when prescribing high doses of statins as these adverse effects are dose-related (see Statin-induced myopathy is rare).20

Treat people without cardiovascular disease to an LDL target of < 2.5 mmol/L

Start people without cardiovascular disease on a statin dose that has a moderate LDL-lowering effect.4,5,7 In major trials, regimens included simvastatin 40 mg10, atorvastatin 10 mg21, or pravastatin 40 mg.22 These regimens lowered LDLD cholesterol levels by about 30% to 40%, reduced the relative risk of major coronary events by about 25% to 35%, and were generally well tolerated.10,21-23 The recommended starting dose of rosuvastatin is 5–10 mg24; while rosuvastatin 20 mg lowered LDL cholesterol by about 50% and reduced cardiovascular events in a large primary prevention trial, the long-term safety of this regimen has not been established in this population.25

When reviewing LDL levels and statin dosage, take into account absolute cardiovascular risk and if greater gains can be had from treating other risk factors. No trials have compared moderate LDL-lowering with more intensive regimens in people without cardiovascular disease.4

C. Recognise that some people identified as moderate or high risk may not qualify for PBS subsidy.
D. Low-density lipoprotein.
E. For a comparison of statin effects on LDL-lowering, see NPS News 71.

Use ezetimibe if a statin alone is inadequate or not tolerated

Ezetimibe is one of several lipid-modifying drugs that can be used for people who cannot tolerate a statin, or can be added to a statin when targets have not been met. Ezetimibe increases the LDL lowering effect of a statin (by up to 20%) and as monotherapy lowers LDL cholesterol by about 18%.15 However, there are limited data on its efficacy in improving cardiovascular outcomes. No trials have shown that ezetimibe monotherapy reduces cardiovascular events. Recent results suggest that ezetimibe plus simvastatin reduces the risk of vascular events in people with chronic kidney disease compared with placebo26, but importantly there are no trial data to show that ezetimibe plus a statin is more effective than a statin alone.

Bile-acid-binding resins reduce LDL cholesterol by about 15% to 25% and there is evidence that cholestyramine improves cardiovascular outcomes.15

Fibrates (gemfibrozil, fenofibrate) and nicotinic acid reduce LDL cholesterol (gemfibrozil less so), but have a more marked effect on triglycerides and HDL cholesterol.15 The effect on cardiovascular event rates of combined therapy with any of these agents and a statin has not been established.

Reserve non-statin lipid-modifying drugs for:

  • people unable to take statins due to contraindications or clinically-important adverse effects
  • combination with a statin when higher statin doses do not adequately reduce LDL cholesterol or are not tolerated. Avoid combining a statin with gemfibrozil or nicotinic acid, and as these combinations can increase the risk of myopathy.12

Statin-induced myopathy is rare: assess symptoms carefully before stopping statins

Muscle pain or discomfort is common in people taking statins, but myopathy is rare, particularly in the absence of risk factors.5

Muscle symptoms were reported at a rate of 1.5% to 3% in both statin and placebo groups in trials.27 Higher rates have been reported in practice, probably because trials excluded people with risk factors or intolerance.27 Myopathy was reported in trials with simvastatin in 0.02%, 0.08% and 0.6% of people who received 20, 40 and 80 mg.28 High doses of all statins are associated with higher incidences of myopathy.24,29

When assessing muscle symptoms in people on statins:

  • rule out other causes (e.g. increased physical activity, trauma, infections)
  • check for risk factors (e.g. dose ≥ 40 mg, age ≥ 70 years, interacting drugs)
  • check creatinine kinase (CK) levels
  • consider reducing the statin dose or switching to a different statin if symptoms are mild
  • stop the statin if muscle symptoms are severe or persistent or if CK > 10 times ULN
  • stop the statin and try a non-statin alternative if muscle symptoms recur on statin rechallenge.15,27,29

Encourage long-term adherence by patients

Regularly remind patients of the benefits of lifestyle changes and lipid modifying therapy.

Support people to make lifestyle changes

Make the most of every opportunity to get people thinking about lifestyle improvements.30 Brief interventions (e.g. 3–5 minutes) by GPs can be a powerful influence on patient intentions.30,31

Use motivational interviewing and a patient-centred approach — see the RACGP Green Book and visit Lifescripts for lifestyle assessment and prescription forms.

Suggest patients contact the Heart Foundation (or 1300 36 27 87) for advice on diet, to find a walking group and other preventive activities. Arrange referral to an accredited dietitian through the dietitians association or exercise physiologist for people who are overweight or obese, and for those with cardiovascular disease.

Regularly remind people about the benefits of statin therapy

Reinforce the benefits of statin therapy to patients at every opportunity. Simple reminders are one of the most effective ways of encouraging adherence32:

  • Ask patients if they know why they are taking the statin and ensure they understand the benefits and side effects.
  • Inform patients that statins work by lowering cholesterol, must be taken continuously to be effective, and have a greater protective effect after the first 1 or 2 years of use.9
  • Advise about the relatively low risk of side effects in the context of over 20 years’ use and experience with these medicines. Assess any co-existing conditions or medicines that may make side effects more likely.
  • Explain that statins provide an added benefit, but do not replace eating a healthy diet or keeping physically active.
Expert reviewers

Professor Andrew Tonkin, Head of Cardiovascular Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne.

Clinical Associate Professor David Sullivan, Department of Biochemistry, Royal Prince Alfred Hospital, Camperdown, Sydney


Dr James Best, General Practitioner, Sydney

A/Prof Nick Buckley, Consultant Clinical Pharmacologist and Toxicologist, University of New South Wales

Jan Donovan, Consumer Representative

Dr John Dowden, Editor, Australian Prescriber

Dr Graham Emblen, General Practitioner, Toowoomba

Deborah Norton, QUM Pharmacist, West Vic DGP

Susan Parker, Pharmacist, Sydney

Dr Jane Robertson, Senior Lecturer, Discipline of Clinical Pharmacology University of Newcastle

Simone Rossi, Managing Editor, Australian Medicines Handbook

Dr Guan Yeo, Clinical Education Consultant and General Practitioner, Berowra

Any correspondence regarding content should be directed to NPS. Declarations of conflicts of interest have been sought from all reviewers. The opinions expressed do not necessarily represent those of the reviewers.

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