Cholesterol
- Reduce CVD risk for all
- Treat to target
- Think Familial Hyperlipidaemia
TOP TIPS
1. The C&M Lifespan Pathway for Lipid Management 2023 provides a clear direction on when, why, and how to use lipid therapies effectively in our population.
2. The NHS lipid pathway on a page is a simple treatment decisions aid for sequencing lipid therapies in primary to secondary prevention, as well as suspecting a diagnosis of familial hypercholesterolaemia.
3. 1 in 250 people have Familial Hypercholesterolemia yet we diagnose <5%; ALWAYS think FH when reviewing cholesterol results. Many remained undiagnosed and undertreated, risking not only the patient’s health but failing to cascade test their family. Offer a cholesterol test to ALL adults at least once under 40 years to avoid missing FH.
4. Use high intensity statins (atorvastatin and rosuvastatin) when prescribing for secondary and primary prevention.
5. Always record CVD risk for primary prevention using QRISK3 for patients who may need primary prevention. QRISK3 should not be used for patients with FH.
6. Treatment target recommendations vary between guidelines, but the consensus is always to treat as low as possible to provide maximal CVD risk reduction.
7. Ezetimibe is recommended for all patients not to target as an add on therapy or alternative if statins are not tolerated.
8. Bempedoic acid is a new drug treatment, working like a statin, to add to Ezetimbe or use as monotherapy when other treatments are not tolerated
9. PCSK9i remain underutilised and are available from specialist lipid services (see NHS lipid pathway for details).
10. UCLP lipid stratification tool is easy to run on GP systems and allows a practice to quickly identify patients who are undertreated requiring review.
THE NATIONAL AMBITIONS: CHOLESTEROL
Improving detection and management of high cholesterol
Too many people are still living with undetected and poorly managed high cholesterol across Cheshire and Merseyside. Public Health England (PHE) and NHS England have agreed national ambitions for the detection and management of high cholesterol and Familial Hypercholesterolaemia over the next 10 years. C&M Health and Care Partnership has committed to achieving these ambitions through a whole-system approach.
The cholesterol ambitions are:
By 2029: 75% of eligible people aged 40 to 74 without established CVD, such as a previous heart attack or stroke, have received a formal validated CVD risk assessment and cholesterol reading recorded on a primary care data system in the last 5 years
By 2029: 45% of people aged 40 to 74 without established CVD, such as a previous heart attack or stroke, identified as having a 20% or greater 10-year risk of developing CVD in primary care are treated with statins
By 2024: 25% of people with Familial Hypercholesterolaemia (FH) are diagnosed and treated optimally according to the NICE FH Guideline. Read more on preventing cardiovascular disease here.
Cheshire and Merseyside Familial Hypercholesterolemia Service
Familial Hypercholesterolaemia (FH) is a genetic condition causing elevated cholesterol levels from birth; it is associated with a significantly increased risk of premature cardiovascular disease, which can be reduced by early detection and effective treatment. The Cheshire and Merseyside FH service has been in operation since September 2022, providing a referral pathway for regional teams to identify possible FH through genetic testing and cascade testing for first degree relatives if FH is diagnosed.
If a patient is diagnosed with FH, patients are counselled by FH service staff and referred back to the referring party with a bespoke management plan in accordance with national lipid management guidance. Specialist guidance is provided alongside eligibility for onward referral to specialist lipid clinic, or paediatric consultant, if indicated. Relatives are invited to self-refer into the FH service for their own genetic testing.
Referral process
To confirm eligibility for genetic testing, the service has developed criteria to be satisfied prior to referral, embedded into their referral form – please request the referral form via this email cm.fhs@nhs.net;.
Discharge from the service
Referrers can expect patients to be assessed for FH and receive counselling prior to and following genetic testing. Treatment with lipid-lowering therapies remains the responsibility of the referrer. Patients will be discharged back to the referrer with one of the following outcomes:
1. Genetically confirmed FH diagnosis with treatment/management recommendations as per regional and national guidance
2. No genetic mutation found: recommendation to follow regional and national guidance in accordance with primary/secondary prevention treatment pathway
3. No genetic testing requested, as the patient was ineligible according to the agreed criteria: recommendation to follow regional and national guidance in accordance with primary/secondary prevention treatment pathway
Contact
For further information about the service, eligibility, referral pathways and support, please contact
Resource Pack
(FH) DLCN criteria
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(FH) Simon Broome Criteria
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(FH) Welsh Genetic testing calculator
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(Frailty) PRISMA-7
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(Regional medicines management drug formularies) Cheshire
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(Regional medicines management drug formularies) Merseyside
View
Ardens Healthcare Informatics
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Clinical Digital Resource Collaborative
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Electronic Medicines Compendium
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IA lipid management webinar resources
View
Patient Resources
Pathway
Primary prevention assessment & identification
Download
Secondary prevention assessment & identification
Download
Statin Intolerance Pathway
Download
Summary of National Guidance for Lipid Management for Primary and Secondary Prevention of CVD
Download
Guidelines
Alirocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia (TA393)
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Bempedoic acid with ezetimibe for treating primary hypercholesterolaemia or mixed dyslipidaemia [TA694]
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Cardiovascular disease: Risk assessment and reduction, including lipid modification (CG181)
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Evolocumab for treating primary hypercholesterolaemia and mixed dyslipidaemia (TA394)
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Ezetimibe for treating primary heterozygous-familial and non-familial hypercholesterolaemia (TA385)
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Familial Hypercholesterolaemia: Identification and Management (CG71)
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National Guidance for Lipid Management
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NICE Icosapent Ethyl
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NICE Inclisiran
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NICE multimorbidity: Clinical Assessment and Management 2016
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