The National Institute for Health and Care Excellence (NICE) guidelines on preventing cardiovascular disease have recently been updated, with significant changes to recommendations on lipid management.1 The new guidance has featured prominently in the national press because of the extended range of patients who are now potentially eligible for lipid-lowering therapy. This reflects a change in emphasis on lipid management towards considering a patient’s lifetime risk of cardiovascular disease (CVD) and the potential benefits of intervening with treatment at a younger age. The guidance also reflects a change towards treating lipid levels to target as opposed to the previous ‘fire and forget’ approach, which will have significant implications for primary care.

NICE continues to recommend using a 10-year CVD risk score, such as QRISK3, to help inform which patients may benefit from primary prevention. According to guidance, those with a 10-year CVD risk score >10% should be offered a statin. However, NICE now suggests that GPs also ‘do not rule out’ treatment for those with a QRISK3 score <10%.1 This new recommendation is supported by a NICE cost-effectiveness analysis that found evidence in favour of statin treatment even down to the youngest modelled age group and QRISK scores of 40 years and 2% respectively.2 However, although there are benefits from statin treatment at a population level, at the individual patient level the absolute risk reduction from statins in people with a QRISK score of 5% is relatively low at 1.9% over 10 years, compared with 7% at the 20% QRISK threshold.3 The higher the QRISK score, the lower the number needed to treat (NNT). NICE estimates that the NNT to prevent a cardiovascular event or stroke with a high-intensity statin for 10 years is 54 at a QRISK threshold of 5%, 25 at a threshold of …