2023+NICE指南：心血管疾病的风险评估和降低包括脂质修饰（英文版NG.238）.pdf

Cardiovascular disease:risk assessment and reduction,including lipid modification NICE guideline Published:14 December 2023 www.nice.org.uk/guidance/ng238 NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Your responsibility The recommendations in this guideline represent the view of NICE,arrived at after careful consideration of the evidence available.When exercising their judgement,professionals and practitioners are expected to take this guideline fully into account,alongside the individual needs,preferences and values of their patients or the people using their service.It is not mandatory to apply the recommendations,and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual,in consultation with them and their families and carers or guardian.All problems(adverse events)related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it.They should do so in the context of local and national priorities for funding and developing services,and in light of their duties to have due regard to the need to eliminate unlawful discrimination,to advance equality of opportunity and to reduce health inequalities.Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.Cardiovascular disease:risk assessment and reduction,including lipid modification(NG238)NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 2 of48Contents Overview.5 Who is it for?.5 Recommendations.6 1.1 Identifying and assessing cardiovascular disease risk for people without established cardiovascular disease.6 1.2 Aspirin for primary prevention of cardiovascular disease.10 1.3 Lifestyle changes for the primary and secondary prevention of cardiovascular disease.10 1.4 Initial lipid measurement and referral for specialist review.13 1.5 Discussions and assessment before starting statins.14 1.6 Statins for primary prevention of cardiovascular disease.17 1.7 Lipid-lowering treatment for secondary prevention of cardiovascular disease.19 1.8 Statins for primary and secondary prevention of cardiovascular disease in people with chronic kidney disease.22 1.9 Optimising treatment for people on statins.23 1.10 Statins are contraindicated or not tolerated.24 1.11 Assessing response to treatment.25 1.12 Lipid-lowering treatments that should not be used or not used routinely.27 Terms used in this guideline.29 Recommendations for research.31 1 Simplifying risk assessment.31 2 Statin treatment for older people.31 3 Lipid-lowering treatment for people with type 1 diabetes.31 Rationale and impact.32 Full formal risk assessment.32 Communication about risk assessment,lifestyle changes and treatment.34 Aspirin for primary prevention of cardiovascular disease.35 Cardioprotective diet.36 Discussions and assessment before starting statins.36 Cardiovascular disease:risk assessment and reduction,including lipid modification(NG238)NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 3 of48Statins for primary prevention of cardiovascular disease.37 Statins for secondary prevention of cardiovascular disease.39 Optimising treatment for people on statins.40 Lipid target for secondary prevention of cardiovascular disease.40 Assessing response to treatment.44 Context.46 Finding more information and committee details.47 Update information.48 Cardiovascular disease:risk assessment and reduction,including lipid modification(NG238)NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 4 of48This guideline replaces CG181.This guideline is the basis of QS5,QS100,QS208 and QS209.Overview This guideline covers identifying and assessing risk of cardiovascular disease(CVD)in adults without established CVD.It covers lifestyle changes and lipid-lowering treatment(including statins)for primary and secondary prevention of CVD,and includes guidance for people who also have diabetes or chronic kidney disease.Who is it for?Healthcare professionals Adults who are at risk of CVD or who have CVD Cardiovascular disease:risk assessment and reduction,including lipid modification(NG238)NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 5 of48Recommendations People have the right to be involved in discussions and make informed decisions about their care,as described in NICEs information on making decisions about your care.Making decisions using NICE guidelines explains how we use words to show the strength(or certainty)of our recommendations,and has information about prescribing medicines(including off-label use),professional guidelines,standards and laws(including on consent and mental capacity),and safeguarding.1.1 Identifying and assessing cardiovascular disease risk for people without established cardiovascular disease Identifying people for full formal risk assessment 1.1.1 For the primary prevention of cardiovascular disease(CVD)in primary care,use a systematic strategy to identify people who are likely to be at high risk of CVD.2008,amended 2014 1.1.2 Prioritise people based on an estimate of their CVD risk before doing a full formal risk assessment.Estimate their CVD risk using CVD risk factors already recorded in primary care electronic medical records.2008 1.1.3 Review estimates of CVD risk on an ongoing basis for people over 40.2008 1.1.4 Prioritise people for a full formal risk assessment if their estimated 10-year risk of CVD is 10%or more.2008,amended 2014 1.1.5 Discuss the process of risk assessment with the person identified as being at risk,including the option of declining any formal risk assessment.2008 Cardiovascular disease:risk assessment and reduction,including lipid modification(NG238)NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 6 of481.1.6 Do not use opportunistic assessment as the main strategy in primary care to identify CVD risk in unselected people.2008 Full formal risk assessment 1.1.7 Use the QRISK3 tool to calculate the estimated CVD risk within the next 10 years for people aged between 25 and 84 without CVD.May 2023 1.1.8 Use the QRISK3 tool for people with type 2 diabetes aged between 25 and 84.May 2023 Until electronic clinical systems in which QRISK2 is embedded are updated with QRISK3,it may be necessary to use QRISK2.When assessing risk for people taking corticosteroids or atypical antipsychotics or people with systemic lupus erythematosus,migraine,severe mental illness or erectile dysfunction,use QRISK3(the online version of QRISK3,if necessary)because QRISK2 does not take these risk factors into account and may underestimate the 10-year CVD risk in these populations.1.1.9 Do not use a risk assessment tool for people who are at high risk of CVD,including people with:type 1 diabetes(see the section on primary prevention of CVD for people with type 1 diabetes)an estimated glomerular filtration rate less than 60 ml per minute per 1.73 m2 and/or albuminuria(see the section on primary and secondary prevention of CVD for people with chronic kidney disease CKD)familial hypercholesterolaemia(see NICEs guideline on familial hypercholesterolaemia)or other inherited disorders of lipid metabolism.May 2023 1.1.10 Recognise that CVD risk tools may underestimate risk in certain groups of people,including but not limited to:Cardiovascular disease:risk assessment and reduction,including lipid modification(NG238)NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 7 of48 people treated for HIV people already taking medicines to treat CVD risk factors people who have recently stopped smoking people taking medicines that can cause dyslipidaemia,such as immunosuppressant drugs people with severe mental illness people with autoimmune disorders,and other systemic inflammatory disorders.May 2023 1.1.11 Consider people aged 85 or older to be at increased risk of CVD because of age alone,particularly people who smoke or have raised blood pressure.May 2023 For a short explanation of why the committee made these recommendations and how they might affect practice,see the rationale and impact section on full formal risk assessment.Full details of the evidence and the committees discussion are in evidence review A:CVD risk assessment tools:primary prevention.Communication about risk assessment,lifestyle changes and treatment 1.1.12 Follow the recommendations on communication in NICEs guidelines on patient experience in adult NHS services and shared decision making.2014 1.1.13 Set aside adequate time during the consultation to provide information on risk assessment and to answer any questions.Arrange for further consultation if needed.2008,amended May 2023 1.1.14 Document the discussion relating to the consultation on risk assessment and the persons decision.2008 Cardiovascular disease:risk assessment and reduction,including lipid modification(NG238)NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 8 of481.1.15 Offer people information about their absolute risk of CVD and the absolute benefits and harms of any intervention over a 10-year period.2008 1.1.16 Consider using a lifetime risk tool such as QRISK3-lifetime to inform discussions on CVD risk and to motivate lifestyle changes,particularly for people with a 10-year QRISK3 score less than 10%,and people under 40 who have CVD risk factors.May 2023 1.1.17 To encourage the person to participate in reducing their CVD risk:find out what,if anything,the person has already been told about their CVD risk and how they feel about it explore the persons beliefs about what determines future health(this may affect their attitude to changing risk)assess their readiness to make changes to their lifestyle(diet,physical activity,smoking and alcohol consumption),to undergo investigations and to take long-term medication assess their confidence to make changes to their lifestyle,undergo investigations and take medication inform them of potential future management options based on current evidence and best practice involve them in developing a shared management plan check that they have understood what has been discussed.2008,amended 2014 1.1.18 If the persons CVD risk is at a level where treatment is recommended but they decline the offer of treatment,advise them that their CVD risk should be reassessed in the future.Record their choice in their medical records.2008,amended 2014 Cardiovascular disease:risk assessment and reduction,including lipid modification(NG238)NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 9 of48For a short explanation of why the committee made the 2023 recommendation and how it might affect practice,see the rationale and impact section on communication about risk assessment,lifestyle changes and treatment.Full details of the evidence and the committees discussion are in evidence review A:CVD risk assessment tools:primary prevention.1.2 Aspirin for primary prevention of cardiovascular disease 1.2.1 Do not routinely offer aspirin for primary prevention of CVD.January 2023 For guidance on using aspirin to prevent venous thromboembolism in over 16s in hospital,see NICEs guideline on venous thromboembolism in over 16s:reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism.NICEs surveillance team reviewed the evidence about aspirin for the primary prevention of CVD.Based on the review,NICE decided to add a do not routinely offer recommendation about this.For full details,see the January 2023 exceptional surveillance report.1.3 Lifestyle changes for the primary and secondary prevention of cardiovascular disease Behaviour change 1.3.1 Advise and support people at high risk of or with CVD to achieve a healthy lifestyle in line with NICEs guideline on behaviour change:general approaches.2014,amended May 2023 Cardiovascular disease:risk assessment and reduction,including lipid modification(NG238)NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 10 of48Healthy eating For advice on healthy eating,see the NHS eat well guide.Cardioprotective diet 1.3.2 Advise people at high risk of or with CVD to eat a diet in which total fat intake is 30%or less of total energy intake,saturated fats are 7%or less of total energy intake,and where possible saturated fats are replaced by mono-unsaturated and polyunsaturated fats.May 2023 1.3.3 Advise people at high risk of or with CVD to:reduce their saturated fat intake increase their mono-unsaturated fat intake with olive oil,rapeseed oil or spreads based on these oils and to use them in food preparation.2014 1.3.4 Take account of a persons individual circumstances,for example,drug treatment,comorbidities and other lifestyle changes,when giving dietary advice.2014 For a short explanation of why the committee made the 2023 recommendation and how it might affect practice,see the rationale and impact section on cardioprotective diet.Full details of the evidence and the committees discussion are in evidence review B:dietary cholesterol strategies.Physical activity 1.3.5 Advise people at high risk of or with CVD to do aerobic and muscle-strengthening activities in line with the UK Chief Medical Officers physical activity guidelines.2008,amended 2014 1.3.6 Encourage people who are unable to perform moderate intensity physical activity Cardiovascular disease:risk assessment and reduction,including lipid modification(NG238)NICE 2023.All rights reserved.Subject to Notice of rights(https:/www.nice.org.uk/terms-and-conditions#notice-of-rights).Page 11 of48because of comorbidity,medical conditions or personal circumstances to exercise at their maximum safe capacity.2008,amended 2014 1.3.7 Advice about physical activity should take into account the persons needs,preferences and circumstances.Agree goals and provide the person with written information about the benefits of activity and local opportunities to be active,in line with recommendation 2 of NICEs gui