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.

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

cm.fhs@nhs.net

Professional: Cholesterol resources