4. Lipid Recommendations

  • Non-fasting blood samples should be taken to measure total cholesterol (TC) and HDL-cholesterol. The JBS3 risk calculator enables entry of these two measures and it is expected that non-HDL-c (TC minus HDL-c = non-HDL-c) will gradually replace LDL-c in clinical practice as well as in clinical trials.
  • All high risk people should receive professional lifestyle support to reduce total and LDL-c, raise HDL-c, and lower triglycerides to reduce their CVD risk.
  • Cholesterol-lowering drug therapy is recommended in:
    • Patients with established CVD
    • Individuals at particularly high risk of CVD: diabetes age > 40 years, patients with CKD stages 3-5, or FH
    • Individuals with high 10-year CVD risk (threshold to be defined by NICE guidance)
    • Individuals with high lifetime CVD risk estimated from heart age and other JBS3 calculator metrics, in whom lifestyle changes alone are considered insufficient by the physician and person concerned
  • Statins are recommended as they are highly effective at reducing CVD events with evidence of benefit to LDL-c levels <2 mmol/L which justifies intensive non-HDL-c lowering.
  • Statins are safe with trial evidence showing no effects on non-cardiovascular mortality or cancer. There is a small increase in risk of developing diabetes but the benefits of cholesterol lowering greatly exceed any risk associated with diabetes. If statin intolerance develops a stepwise strategy involving switching agents and re-dosing is recommended.
  • Despite low HDL-c levels contributing to CVD risk, drug therapy to raise HDL has not been shown to reduce CVD risk and is not currently indicated.