Summary: QRISK predicts cardiovascular disease, and is routinely completed for a wide range of patients. QRISK, and comorbidities, are used to estimate an individuals risk for cardiovascular events.
Intended Users: Pharmacists & GPs
QRISK
QRISK2 calculates a person's risk of experiencing a heart attack or stroke over the next 10 years, calculated using averages of individuals with the same risk factors
QRISK can be calculated on EMIS, using the template “QRISK2”
For a reliable calculation, cholesterol, BP & BMI should have been completed in the last 6 months, smoking, ethnicity and family history should also be complete.
QRISK shouldn’t be used in patients who:
- Already have CVD (Such as having angina, or previously having an MI or Stroke)
- Are already at a higher risk of CVD due to familial hypercholestrolaemia, Type 1 Diabetes, or an eGFR <60
- Aged >85 (Considered high risk on age alone, especially smokers & ↑BP)
General Statin Advice
- If LDL >2.6, and statins are contraindicated or not tolerated, A+G to lipid clinic for advice on starting Inclisiran
- Arrange for specialist assessment of people with a total blood cholesterol level of >9.0 mmol/L or a non-HDL cholesterol level of >7.5 mmol/L even in the absence of a first-degree family history of premature coronary heart disease
- For people aged 85 and older consider treatment with atorvastatin 20mg OD
- If patient has CVD + CKD: aim for at least 40% reduction in non-HDL to start
Pregnancy & Statins
Statins are contraindicated in pregnancy due to exposure risks to the unborn child.
Explain to all women of child-bearing potential:
- Statins should be stopped if there is a possible pregnancy
- Statins should be stopped 3 months before attempting to conceive
- Statins should not be restarted until breastfeeding is finished
Primary Prevention
Primary Prevention targets people who do not have established CVD, but are at risk of a first cardiovascular event
- Offer Statins to patients with:
- QRISK >10% (incl. T2DM patients)
- all CKD patients
- T1DM and aged >40
- T1DM for >10 years
- T1DM with nephropathy
- T1DM with other CVD risk factors
- At-risk people include those with QRISK >10%, history of T1DM, T2DM, CKD, or Familial Hypercholesterolemia, and people >85.
- Lipid Target: non-HDL reduction of ≥40% from baseline
Secondary Prevention
Secondary prevention aims to reduce the risk of recurrent cardiovascular events in people with established CVD
- This includes patients with a history or current diagnosis of CVD, MI, angina, stroke, TIA or PAD
- Lipid Target: HDL ≤2.6mmol/L or LDL ≤2.0 mmol/L
Statin Intolerance and Contraindication
- If high-intensity statin therapy is not tolerated, and is unable to tolerate a low-intensity statin, (i.e. due to statin-related muscle pain, a unilateral pain worsened by exercise) reduce the statin to the most tolerated dose. It is better to be on any statin compared to no statin.
- If unable to tolerate low-dose, low-intensity: Change to Ezetimibe 10mg OD only. Check Lipid profile after 3 months, aiming for >40% reduction in LDL.
- If not achieved, add Bempedoic Acid 180mg, in the form of Nustendi 180mg/10mg OD - Check uric acid, FBC, LFT and renal before starting. Check Lipid profile after 3 months, and if not achieved, seek specialist advice
Consider low dose rosuvastatin 5mg once a week day or three times a week.
Statin Classes
Intensity is based upon the percentage reduction in LDL cholesterol each can produce.
High-intensity
- Atorvastatin 20-80mg
- Rosuvastatin 10-40mg
Medium-intensity
- Atorvastatin 10mg
- Fluvastatin 80mg
- Rosuvastatin 5mg
- Simvastatin 20mg-40mg
Low-intensity
- Fluvastatin 20-40mg
- Pravastatin 5-40mg
- Simvastatin 10mg
