Worldwide cardiovascular disease is by far our biggest killer with acute myocardial infarction and stroke being the two biggest killers internationally.

High cholesterol, along with high blood pressure, altered blood sugars, obesity, chronic kidney disease and atrial fibrillation are all to be found and optimally treated. We need to continue to reduce smoking in the UK and we've been successful in doing this over the last two decades. If we do this the impact will be large avoiding over 60,000 cardiovascular events making substantial savings in both NHS costs and lost taxes as younger people who have cardiovascular events often become economically inactive.

There is clear realisation that this rebalance towards prevention is variable throughout the country, with marked inequities in certain harder to reach groups, and we need to standardise the care to those highlighted by the national guidance. Lipid optimisation both for people with established cardiovascular disease and patients without known cardiovascular disease is a primary objective.

The document names 12 priorities to find the missing millions, drive treatment to target, ensure timely equitable high-quality care with expansion of rehabilitation services. Ambitious metrics have been produced with both three-year and 10 year ambitions to support delivery at pace and scale. However good our prevention strategies are, we know that with an ageing, multi-morbid population that the number of people having a stroke is set to rise significantly over the next decade. This is why the delivery of specialised stroke care is one of the priority areas with the MSF. Currently less than half of patients get evidence-based specialised and organised stroke care – the three-year ambition is to raise this to 75% and the ten-year ambition is 85%.

This all means that the know your numbers campaign should include a full lipid profile. We know from many studies including our pan-European Santorini study that the majority of patients at both high risk and very high risk of cardiovascular events are not on optimal lipid lowering therapy. Historically, there was a fire and forget policy regarding the use of statin monotherapy. Often these were not used at optimal doses and, if the patient couldn't tolerate the statin, they simply got nothing. There is a clear realisation that alternatives to statins now exist. The Clear Outcomes trial demonstrated that the alternative cholesterol synthesis inhibitor bempedoic acid had large benefits and was especially useful in primary prevention. When combined with ezetimibe in a single tablet this could reduce LDL cholesterol by 38% which is greater than some of the older, less potent statins. This means that patients should be offered statin therapy with a high potency statin at a reasonable in primary prevention if their Qrisk score is 10% or more for 10 years but, if they cannot tolerate this, they should be given alternative therapy. In those patients with known cardiovascular disease, the treatment targets should be lower, and it is realised the only way to achieve this is using combinations of lipid lowering therapies. The recent publication of the Vesalius study in patients at higher risk but without a previous cardiovascular event showed that the addition of PCSK9i targeted therapy on top of optimised oral therapy provided a substantial reduction in mortality when used long term.

However, people worry about lowering cholesterol and its effect on the brain. Interestingly, in the large Fourier study of 27,500 patients worldwide we showed that intensive lipid lowering therapy had no effect on brain function but delivered a significant reduction in strokes. There was no significant increase in the risk of haemorrhagic stroke. The median LDL in this study was 0.8 millimoles per litre in the active grouping suggesting that low LDL is not worrisome. In 2023, the American Heart Association made a statement that lower is better when it comes to cholesterol to avoid strokes. The recent publication of the Danish experience comparing giving statins to people with diabetes either in their diagnosis, later on in treatment or where no lipid lowering was prescribed, clearly showed that earlier usage of lipid lowering therapy is associated with a significant reduction in dementia.

All this data suggests we need to measure the lipid profile of the population, work out the risk of them having strokes and heart attacks and offer appropriate patients lipid-lowering therapy to prevent cardiovascular events. In doing so we will save lives and money. This is our biggest killer and we can prevent it – if we do it well, just think how may people we can avoid going through the devastation of a stroke or a heart attack.

Article written by The Primary Care Cardiovascular Society