NICE’s simplified approach to lipids will not work

Although starting all patients on simvastatin 40 mg for secondary prevention is a sound approach for many,¹ a substantial proportion will not achieve the targets of less than 4 mmol/l for total cholesterol and 2 mmol/l for low density lipoprotein (LDL) cholesterol with this therapy.

A meta-analysis by Law et al in 2003 showed that simvastatin 40 mg achieves a reduction in LDL cholesterol of 37%.² This implies that as initial therapy, any patient with an LDL measurement higher than 3.1 mmol/l would not be treated to target with simvastatin 40 mg. In the same study, simvastatin 80 mg achieved a 42% reduction in LDL; atorvastatin 40 mg and rosuvastatin 20 mg achieved reductions of 49% and 48%, respectively.

Starting patients with an LDL of greater than 3.1 mmol/l on simvastatin 40 mg seems to mean that their treatment will inevitably have to be escalated at a later date. This will result in additional clinician time, additional blood tests for the patient, and potentially some patients remaining suboptimally treated. Cheshire and Merseyside Cardiac Network advises starting atorvastatin 40 mg in all patients with a total cholesterol concentration higher than 6 mmol/l, and in practice this approach seems effective.³ It is a shame that a similar tactic was not employed by the National Institute for Health and Clinical Excellence (NICE).