3rd June 2026

Medical management

Lifestyle interventions

Lifestyle change support, such as weight management and smoking cessation should be offered before commencement of medication in primary prevention. 

If managing secondary prevention, lifestyle measures should be discussed alongside initiation of treatment. 

Risk factor control

Blood pressure: Target BP <140/90mmHg in low risk. Target BP should be 130/80mmHg in high-risk patients (established atherosclerosis, CKD, diabetes).

Glycaemic control: Aiming for a fasting glucose <6mmol/L and HbA1c of less than 6.5% 

Antiplatelet therapy: If patients have known peripheral or coronary disease caused by atherosclerosis, then aspirin 75mg OD should be considered, with clopidogrel as a second-line choice. Aspirin should not be considered in primary prevention, as the risk of GI bleeding outweighs the benefits.

Pharmacological Management

Lipid-lowering agents such as Atorvastatin 20mg are used for primary prevention if QRISK3 > or equal to 10%. The latest guidance from NICE advises to ‘not rule out’ those with a QRISK score of less than 10% for treatment. Atorvastatin 80mg is used for secondary prevention regardless of cholesterol level.

Repeat lipid levels and LFTS must be checked in 3 months of starting a lipid-lowering agent, then annually. Non-HDL cholesterol targeted with greater than or equal to 40% reduction for primary prevention. Non-HDL target is ≤ 2.6mmol/L or LDL target is ≤ 2.0 mmol/L for secondary prevention. 

Clinicians should increase the dose of the statin if these are not met, and the patient agrees. If the target level is still not achieved post an increase in dose, Ezetimibe 10mg OD can be added in.

If target is still not achieved, newer lipid-lowering agents (PCSK9 inhibitors or inclisiran) may be added in, however, these may need to be discussed with specialist care. 

Please see (Williams et al., 2024) for a summary of the NICE guidelines regarding primary and secondary prevention.