Cardiovascular disease prevention: lipid management

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After completing this CPD module, pharmacists will have a better understanding of community pharmacy case-finding, point-of-care testing, risk calculation and independent prescribing in preventing CVD and its complications.

Author: Alison Warren FRCPharm, DipClinPharm, MSc, PharmIP; consultant pharmacist in cardiology, University Hospitals Sussex and Sussex ICB

Module overview

Cardiovascular disease (CVD) is a leading cause of premature mortality. However, much of the disease burden is preventable through better identification and management of modifiable risk factors. Community pharmacy is uniquely placed to work with general practice as part of an integrated neighbourhood care team to deliver enhanced CVD prevention services.

The aim of this module is to consider the importance of cholesterol as a risk factor for cardiovascular disease and how community pharmacy teams can play an integral role in timely ‘at risk’ patient identification and management.

The module will consider potential roles within community pharmacy, such as measuring lipid profiles, interpreting results, calculating and interpreting 10-year CVD risk scores, as well as supporting patients to reduce risk through lifestyle advice and, where indicated, shared decision-making regarding lipid-lowering medication. This may involve treatment initiation, ongoing monitoring or medication optimisation to treat patients to guideline-directed targets.

There are national and international guidelines with clear recommendations for treatments that are highly effective at preventing CVD, but these remain substantially underused. The challenge is how to improve their reach and implementation. Community pharmacy, with its unique patient footprint, can be a key player.

As well as focusing on cholesterol as a CVD risk factor, this module also provides an overview of target patient groups, as well as highlighting other opportunities for expanding the clinical role of community pharmacy in CVD prevention.

Introduction

If plans for NHS reform in England are to come to fruition as the Government intends, community pharmacies will need to play an important role. The intention is to bring care closer to home by developing multidisciplinary neighbourhood teams.

Central to this vision is the principle that care should be delivered as locally as possible – and this is where community pharmacy comes in. Importantly, the NHS is also seeking to expand the role of pharmacists in managing long-term conditions, and to provide access to the single patient record to help facilitate this.

It is estimated that more than 7.6 million people in the UK live with CVD, which contributes substantially to emergency admissions, and health and social care costs. However, much of this burden is preventable. Up to 80% of premature CVD deaths are associated with modifiable risk factors.

Supporting the prevention of CVD presents numerous opportunities, beginning in childhood and continuing throughout adult life. These include promoting healthy lifestyles and supporting services aimed at smoking cessation, improving diet, reducing obesity, reducing harmful alcohol consumption, and increasing participation in regular physical activity.

The health and wellbeing services already provided by community pharmacy can be expanded to support this prevention agenda.

Proactive prevention

In addition, proactive prevention of CVD involves identifying and managing high-risk conditions such as hypertension, hypercholesterolaemia, chronic kidney disease, and diabetes.

There are national and international guidelines with clear recommendations for treatments that are highly effective at preventing CVD, but these interventions remain substantially underused. The challenge for primary care is how to improve their uptake and implementation.

Community pharmacy hypertension case-finding services were introduced several years ago and are regarded as a success. Uptake has been widespread. From April 2024 to February 2025, 199,182 blood pressure checks were carried
out by community pharmacies in England, exceeding the target for that period by 181% and demonstrating once again how investment in community pharmacy services can support the CVD prevention agenda.

Cholesterol as a CVD risk factor

Cholesterol is an essential component of healthy cells and is required to produce vitamins and certain hormones. However, excessive cholesterol levels, leading to the development of atheroma within the arteries, can result in serious conditions including coronary heart disease, stroke and peripheral arterial disease.

A 1 mmol/L reduction in low-density lipoprotein cholesterol (LDL-C) reduces the relative risk of CVD by around 25%. Furthermore, it is increasingly recognised that, although cholesterol levels are important, the duration of exposure to elevated cholesterol levels (the so-called cholesterol burden) is also a key determinant of cardiovascular risk.

Cholesterol results should therefore be interpreted in the context of an individual’s overall CVD risk profile, emphasising the importance of early identification and management.

Target groups

There are three key groups of people for whom an increased focus on lipid management is particularly important:

• Those with risk factors for CVD but do not yet have established disease (primary prevention)
• Those with established CVD, such as previous myocardial infarction, angina, stroke, transient ischaemic attack (TIA), or peripheral arterial disease (secondary prevention)
• Those with inherited forms of high cholesterol. The most common is heterozygous familial hypercholesterolaemia (FH), which is associated with elevated cholesterol levels from birth and premature CVD within families.

Measuring lipid profiles

Cholesterol is transported in the bloodstream attached to proteins known as lipoproteins. The two principal types are low-density lipoprotein (LDL) and high-density lipoprotein (HDL).

LDL cholesterol (LDL-C) is often referred to as ‘bad’ cholesterol because it can accumulate within the arteries, causing them to narrow and harden (atherosclerosis) and reducing blood flow. This process can ultimately lead to a heart attack or stroke.

HDL cholesterol (HDL-C) is commonly known as ‘good’ cholesterol because it carries excess cholesterol away from the arteries and back to the liver, where it is broken down and removed from the body. Maintaining healthy HDL-C levels may help protect against heart attack and stroke.

A third component, triglycerides, also plays an important role in lipid health. Triglycerides are the body’s main form of stored fat and provide a source of energy. Being overweight, consuming large amounts of fatty or sugary foods, poorly controlled diabetes and excessive alcohol intake can all contribute to raised triglyceride levels.

Triglyceride levels may actually be elevated despite relatively normal LDL-C and non-HDL cholesterol levels. A raised triglyceride level, combined with low HDL-C and high LDL-C, can further increase CV risk.

The usual method of assessing cholesterol levels is for the GP practice to send a non-fasting blood sample to the local pathology service, which provides a full lipid profile. The components of a lipid profile are shown in Table 1, together with typical laboratory reference ranges.

Access to blood test results is not yet routinely available in community pharmacy. However, pharmacists can ask whether patients use the NHS App, through which they may be able to view their blood test results and share them during the consultation. It is important that pharmacy teams are familiar with the NHS App, understand how blood test results are displayed, and know how to interpret the information.

Point-of-care testing

An alternative to sending a blood sample to the pathology service is the use of point-of-care testing (POCT), which provides rapid results in a clinical setting. This approach offers several advantages, including improved accessibility, the opportunity to discuss results during a single consultation, and earlier initiation and/or optimisation of treatment without the need for additional appointments.

It is essential, however, that POCT systems are appropriately validated. A rapid review published in 2025 examining the accuracy of POCT for cholesterol measurement evaluated the evidence supporting six different systems and demonstrated that some are better validated than others. The introduction of POCT into routine clinical practice therefore requires careful selection and commissioning of equipment, together with appropriate quality assurance processes and validated platforms for calculating cardiovascular risk.

Primary prevention

Identifying cardiovascular risk

Several risk factors increase the likelihood of developing CVD. Identifying people at increased risk allows preventative measures to be implemented before cardiovascular disease develops. Risk factors can broadly be divided into modifiable and non-modifiable categories:

Modifiable risk factors

• Weight
• Smoking status
• Blood pressure
• Cholesterol
• Diabetes.

Non-modifiable risk factors

• Age
• Sex
• Ethnicity
• Family history.

Identifying someone at increased risk provides an opportunity to introduce preventative interventions, such as lifestyle modifications or medicines to reduce cardiovascular risk, with the aim of delaying or preventing the onset of CVD.

Assessment of CV risk is already embedded within the NHS Health Check programme, but more widespread risk assessment could improve the identification of individuals who may benefit from earlier intervention.

Cardiovascular risk assessment

The recommended approach to identifying a person at increased risk of CVD is the use of a validated CV risk score. Several tools are available.

The QRISK3 tool is recommended by NICE, while the ASSIGN risk score is recommended by SIGN and is used in Scotland. These web-based tools estimate the percentage risk of developing CVD, including coronary heart disease, stroke, and transient ischaemic attack, over a period of the next 10 years.

The assessment should be completed as fully as possible to improve its accuracy and requires the collection of demographic and clinical information, including height, weight, blood pressure, and cholesterol measurements.

Table 2 summarises the information required to complete a QRISK3 assessment.

Undertaking a CVD risk assessment

Much of the information required to undertake a CVD risk assessment can be obtained during a structured consultation in community pharmacy. However, one important element that may be unavailable is the patient’s lipid profile. This is where access to results through the NHS App or using POCT may be particularly valuable.

A major advantage of commissioning this service within community pharmacy is the accessibility and ability to reach people who may not routinely engage with general practice, 

as has already been demonstrated through the hypertension case-finding service. This approach therefore has the potential not only to increase uptake but also to help reduce health inequalities.

Interpreting a CVD risk assessment

A 10-year CVD risk score of 10% or more is considered a high level of risk and, alongside lifestyle interventions, is the threshold for considering lipid-lowering therapy to reduce cardiovascular risk.

It is important to remember that this is an estimate and that CV risk may be underestimated in certain groups of people, including those:

• Living with HIV
• Already receiving medicines to treat CVD risk factors
• Who have recently stopped smoking
• Taking medicines that can cause dyslipidaemia
• With autoimmune or other systemic inflammatory disorders.

If a patient is identified as being at high risk through POCT or formal risk assessment, pharmacy teams should use the opportunity to discuss lifestyle modification and introduce the option of lipid-lowering therapy (LLT).

It should also be recognised that some people with a calculated risk below 10% may still wish to consider lipid-lowering treatment, and this may be appropriate following an informed discussion of risks and benefits.

At present, patients would generally need to be referred to general practice for further evaluation, exclusion of secondary causes of hyperlipidaemia, and consideration of LLT initiation. In line with current NICE and SIGN guidance, first-line treatment is likely to be a high-intensity statin, such as atorvastatin 20mg once daily.

If treatment is initiated, the patient may subsequently return to the pharmacy with their prescription, creating an opportunity for a further consultation through the New Medicine Service to support adherence and optimise treatment outcomes.

Secondary prevention

People with established CVD are already considered to be at high cardiovascular risk, so the use of primary prevention risk assessment tools is neither necessary nor appropriate. The expectation is that these patients will already be receiving lipid-lowering therapy, with the aim of reducing LDL cholesterol (LDL-C) to guideline-directed targets.

Current NICE guidance recommends an LDL-C target of less than 2.0 mmol/L. However, it should be recognised that some international guidelines, including those from the European Society of Cardiology (ESC), recommend lower treatment targets for certain high-risk groups.

Within community pharmacy, these patients may be identified through referral pathways – for example, via the Discharge Medicines Service (DMS) – or through review of the patient’s medication record.

Community pharmacy teams can support the ongoing optimisation of lipid-lowering therapy for secondary prevention. This may include:

• Supporting adherence to long-term treatment
• Helping patients manage adverse effects
• Identifying patients who no longer have an active prescription for lipid-lowering therapy
• Reviewing lipid profile results to assess whether guideline targets are being achieved
• Supporting referral or treatment escalation where further optimisation may be required.

Familial hypercholesterolaemia

Early identification of inherited forms of high cholesterol can help prevent premature cardiovascular disease.

Heterozygous familial hypercholesterolaemia (FH) results from the inheritance of a pathogenic gene variant from one parent and causes markedly elevated cholesterol levels from birth. The prevalence is estimated to be approximately 1 in 250-500 people, although the condition remains under-recognised and underdiagnosed.

The condition is associated with premature cardiovascular disease. If left untreated, approximately 50% of men develop CVD by the age of 50 years and 30% of women by the age of 60 years.

Diagnosis is usually made following referral to a lipid specialist, who may arrange genetic testing. Once a diagnosis has been confirmed, testing should be offered to family members through specialist services because there is a 1-in-2 chance that a first-degree relative, such as a sibling or child, will also have the condition.

When undertaking or reviewing lipid profile results in community pharmacy, pharmacists should consider the possibility of FH. In adults, FH should be suspected if:

• Total cholesterol is greater than 7.5 mmol/L, or
• There is a personal or family history of premature CVD (defined as an event before the age of 60 years in the individual or a first-degree relative).

In addition to referral to the patient’s GP, obtaining further information about the family history can help prepare the patient for the consultation and facilitate subsequent assessment. Importantly, even in the absence of established CVD, the QRISK tool should not be used in suspected FH because it is likely to underestimate cardiovascular risk.

Community pharmacists can also support patients newly prescribed lipid-lowering therapy for FH, as well as ongoing adherence and treatment optimisation to achieve LDL-C targets.

Conclusion

This module has focused on cholesterol as a modifiable risk factor for CVD and has outlined the role of community pharmacy in identifying and supporting people at increased cardiovascular risk. It has also explored future opportunities for pharmacy, including cholesterol testing, CVD risk assessment, and the prescribing, monitoring and optimisation of lipid-lowering therapies.

These developments can build on existing healthy living services in community pharmacy and also make effective use of pharmacists’ expanding clinical skills as independent prescribers.