While mortality from acute cardiovascular disease (CVD) has been falling in most developed countries, more people are now living with established CVD, including coronary heart disease, peripheral arterial disease, and stroke or transient ischaemic attack. These individuals remain at high risk of subsequent cardiovascular events and mortality. In the UK, the cost of treating a myocardial infarction is £1310 higher in the first year for someone with established CVD than for a first event.1 Secondary prevention interventions, such as lowering of low density lipoprotein cholesterol (LDL-C), mitigate this risk and improve outcomes.2
Statins, ezetimibe, bempedoic acid, and injectable therapies are approved as lipid lowering therapies in the UK. However, use of these agents is variable,3 with about one fifth of people with CVD in England receiving no lipid lowering therapy.4 This is partly because of the absence of nationally agreed LDL-C targets for people with CVD to inform need for therapeutic escalation. Targets between 1.4 mmol/L and 1.8 mmol/L have been advocated by specialist societies and expert consensus, based on data from randomised controlled trials (RCTs).56 Achievement of these targets has been poor, and as of September 2023, in England, only about one third of people with CVD who had a cholesterol test in the last 12 months had either LDL-C below 1.8 mmol/L or non-HDL-C below 2.5 mmol/L.7
This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE), first …