Cardiovascular risk reduction - quality prescribing guidance 2026-2029: consultation

4. Summary of recommendations

4.1 Hypertension in adults

• Hypertension in adults should be diagnosed and treated as per National Institute for Health and Care Excellence (NICE) Guidance 136
• Individuals should be identified who need referred for same-day specialist review as per NICE 136
• People with hypertension should be advised to reduce their salt intake as much as possible to lower blood pressure
• When choosing an antihypertensive medication, the individual should be at the centre of any decision. Discuss individual cardiovascular disease risk and the individual’s preferences for treatment, including no treatment, and explain the risks and benefits before starting antihypertensive drug treatment
• A suitable algorithm such as NICE or the British and Irish Hypertension Society (BIHS) adult hypertension referral pathway for therapeutic management should be utilised when choosing an antihypertensive medication considering the individual's age, family origins and comorbidities
• Clinical judgement should be used when prescribing in individuals with frailty or multimorbidity

4.2 Hyperlipidaemia

• Non-fasting sampling of lipid parameters is recommended for general risk screening
• Measure both total blood cholesterol and high-density lipoprotein (HDL) cholesterol to achieve the best estimate of CVD risk
• Primary prevention using a statin is recommended in individuals with:
• ASSIGN v2.0 (ASsessing cardiovascular risk using SIGN guidelines to assign preventive treatment) score ≥10%
• Chronic Kidney Disease Estimated Glomerular Filtration Rate (CKD eGFR) <60 or Albumin-to-Creatinine Ratio (ACR) >3mg/mmol (approx. equal to 30mg/g)
• Familial hypercholesterolaemia (FH)
• Type 1 diabetes who are over 40 years old, or disease duration >10 years, or nephropathy or other CVD risk factors
• Atorvastatin 20mg daily is the statin of choice in primary prevention
• Consider ezetimibe
• where initial statin therapy is contraindicated or individuals cannot tolerate statin therapy
• co‑administered with initial statin therapy when Serum total or Low-density Lipoprotein (LDL) cholesterol concentration is not appropriately controlled or a change from initial statin therapy to an alternative statin is being considered
• If treatment is initiated, its effect must be evaluated, and subsequent treatment intensification to reach ultimate risk factor goals must be considered in all patients, taking into account additional benefit, comorbidities, and frailty, all of which converge with patient preferences in a shared decision-making process
• The absolute benefit of lowering Low-Density Lipoprotein Cholesterol (LDL-C) depends on the absolute risk of Atherosclerotic Cardiovascular Disease (ASCVD) and the absolute reduction in LDL-C, so even a small absolute reduction in LDL-C may be beneficial in a high- or very-high-risk patient

4.3 Pharmacotherapies for obesity

• Ask for permission each time before discussing overweight, obesity or central adiposity and before taking measurements
• In adults with Body Mass Index (BMI) below 35 kg/m², measure and use their waist-to-height ratio, as well as their BMI, as a practical estimate of central adiposity and use these measurements to help to assess and predict health risks (for example, type 2 diabetes, hypertension or cardiovascular disease)
• Incretin-based therapies should be considered for those who meet SMC/consensus statement criteria

4.4 Diabetes

• Primary care healthcare professionals should implement a two-stage strategy to identify people at high risk of type 2 diabetes (and those with undiagnosed type 2 diabetes)
• Firstly, a risk assessment should be offered
• Secondly, for those with high-risk scores, a blood test should be offered to investigate if they have type 2 diabetes or prediabetes
• Reassess people with a high-risk score, but with a Glycated Haemoglobin (HbA1c) less than 42mmol/mol (6.0%) or a fasting plasma glucose less than 6.1mmol/L, every three years
• Reassess people with a low or intermediate risk score every five years using a validated risk-assessment tool
• Use clinical judgement to determine when someone might need to be reassessed more frequently, based on their combination of risk factors.
• Metformin should be considered as the first-line oral treatment option for people with type 2 diabetes
• NICE 28 flowchart should be utilised when choosing medication considering the individual's cardiovascular status, risk of developing cardiovascular disease in the future, renal status and if considered clinically significantly frail

4.5 Smoking

• All people who smoke should be advised to stop and offered support to help facilitate this in order to minimise cardiovascular and general health risks
• At every opportunity, ask people if they smoke or have recently stopped smoking
• Varenicline or combination nicotine replacement therapy should be offered alone or as part of a smoking cessation programme to augment professional advice and increase long-term abstinence rates