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Atherosclerotic cardiovascular disease (ASCVD) is a type of cardiovascular disease that includes previous acute coronary syndrome (myocardial infarction or unstable angina), stable angina, coronary revascularisation (percutaneous coronary intervention, coronary artery bypass graft surgery, and other arterial revascularisation procedures), stroke and transient ischaemic attack, and peripheral arterial disease.1
Cardiovascular disease is the leading cause of mortality worldwide, accounting for an estimated 17.9 million deaths per year.2 Most cardiovascular disease deaths globally are due to ASCVD.3
In the UK, around:4
7.6 million people live with cardiovascular disease
160,000 deaths each year are caused by cardiovascular disease
100,000 hospital admissions each year are due to heart attacks
Most risk factors for cardiovascular disease are modifiable, including:2,5,6
High levels of low-density lipoprotein (LDL) cholesterol
Hypertension
Diabetes
Smoking
Unhealthy diet
Obesity
Physical inactivity
Harmful alcohol consumption
Other, non-modifiable risk factors include:5
Age
(being over the age of 50)
Gender
(men are more likely to have cardiovascular disease at an earlier age than women)
Family history of cardiovascular disease and ethnicity
(in the UK, people of South Asian and Black African or African Caribbean background have an increased risk of cardiovascular disease)
Several conditions can influence the risk of cardiovascular disease, either by:6
- Increasing its likelihood
- Contributing to poorer clinical prognosis
Around 80% of people with cardiovascular disease have at least one other health condition,4 making it important to screen these patients for ASCVD risk factors. These other health conditions include:6
Since many of these clinical conditions share common cardiovascular disease and ASCVD risk factors, treating them would allow a synergistic reduction in the overall burden of disease.6
Cardiovascular disease is one of the conditions most strongly associated with health inequalities, with many people still living with undetected, high-risk conditions.7,8 A population approach may help narrow the gap in health inequalities, preventing other health conditions linked to ASCVD and cardiovascular disease.6
Cardiovascular disease places a considerable financial burden in England, costing the NHS about £7.4 billion/year9
Long-term exposure to persistently elevated LDL cholesterol is causal to ASCVD.10,11
Around 42,000 cardiovascular deaths/year are linked to elevated LDL cholesterol in the UK4 – that’s why knowing LDL cholesterol levels is important for risk management.
Plasma LDL cholesterol can be measured directly using enzymatic techniques or preparative ultracentrifugation, but in clinical medicine it is most often estimated from the concentration of total cholesterol and HDL cholesterol (included in a standard serum lipid profile), using the Friedewald formula:*1
LDL cholesterol (mmol/L) = total cholesterol – HDL cholesterol – (triglycerides/2.2)
Or
LDL cholesterol (mg/dL) = total cholesterol – HDL cholesterol – (triglycerides/5)
The Friedewald formula allows to calculate the levels of LDL cholesterol both in mmol/L (more common in Europe) and in mg/dL (more common in the United States). This means you can get the molarity and also the concentration of LDL cholesterol by the ratio of weight to volume, and use whatever is more relevant to you.
*The Friedewald formula cannot be used if triglycerides are >4.5 mmol/L or >400 mg/dL. Other well-established limitations of the formula include methodological errors that may accumulate (since the formula requires 3 separate analyses of total cholesterol, triglycerides, and HDL cholesterol), and the fact that a constant cholesterol/triglycerides ratio in very-low density lipoprotein is assumed.1
Primary and secondary prevention of cardiovascular disease – UK guidance14
The NHS, through the Accelerated Access Collaborative, has developed a NICE-endorsed lipid management pathway that includes current lipid-lowering therapies. Updated in December 2022, this pathway brings relevant NICE guidance and technology appraisals together into a single document to aid decision making for clinicians, helping to improve outcomes and reduce variation in treatment.14,15
This link will take you to the NHS website, which is a non-Novartis website.
LDL-C target value
Adapted from Mach F et al. 2020.13
2021 ESC Guidelines on cardiovascular disease prevention in clinical practice6
The European Society of Cardiology (ESC) has collaborated with the Task Force for cardiovascular disease prevention in clinical practice and 12 medical societies including the special contribution of the European Association of Preventive Cardiology (EAPC). The guidelines summarise and evaluate the available evidence on atherosclerotic cardiovascular disease (ASCVD) with the aim of helping healthcare professionals achieve treatment goals and reduce the burden of the disease for patients and the wider population whilst pursuing patient preferences.6
This link will take you to the NHS website, which is a non-Novartis website.
2019 ESC/EAS LDL cholesterol goals are even lower than national ones: they recommend LDL cholesterol <1.4 mmol/L and ≥50% LDL cholesterol reduction from baseline for all ASCVD patients1
Watch the video below to learn more about the consequences of long-term exposure to persistently elevated LDL cholesterol.
It is estimated that there are over 3.5 million people with ASCVD in the UK16
Take the opportunity to review lipid management in these patients as they may be visiting your clinic more often than you think due to other health conditions.17
ASCVD, atherosclerotic cardiovascular disease; ESC/EAS, European Society of Cardiology/European Atherosclerosis Society; HDL, high-density lipoprotein; LDL, low-density lipoprotein; NHS, National Health Service; NICE, National Institute for Health and Care Excellence.
References
- Mach F et al. Eur Heart J 2020;41(1):111–188.
- World Health Organization. Cardiovascular diseases (CVDs). Available at: https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds) [Accessed February 2023].
- Roth GA et al. J Am Coll Cardiol 2020;76(25):2982–3021.
- British Heart Foundation. UK Factsheet. Available at: https://www.bhf.org.uk/-/media/files/for-professionals/research/heart-statistics/bhf-cvd-statistics-uk-factsheet.pdf [Accessed February 2023].
- National Health Service. Cardiovascular disease. Available at: https://www.nhs.uk/conditions/cardiovascular-disease/ [Accessed February 2023].
- Visseren FLJ et al. Eur Heart J 2021;42(34):3227–3337.
- National Health Service. The NHS Long Term Plan. Available at: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term... [Accessed February 2023].
- Heart UK. Prioritising the prevention of cardiovascular disease (CVD). Available at: https://www.heartuk.org.uk/downloads/health-professionals/heart-uk-cvd-p... [Accessed February 2023].
- UK Health Security Agency. Health Matters: Preventing cardiovascular disease. Available at: https://publichealthmatters.blog.gov.uk/2019/02/14/health-matters-preven... [Accessed February 2023].
- Ference BA et al. J Am Coll Cardiol 2018;72(10):1141–1156.
- Ference BA et al. Eur Heart J 2017;38(32):2459–2472.
- Libby P et al. Nat Rev Dis Primers 2019;5(1):56.
- Libby P et al. Nature 2011;473(7347):317–325.
- National Health Service. Summary of national guidance for lipid management for primary and secondary prevention of CVD. Available at: https://www.england.nhs.uk/aac/wp-content/uploads/sites/50/2020/04/Natio... {Accessed February 2023].
- Heart UK. AAC publisges updated clinical pathway for lipid management. Available at: https://www.heartuk.org.uk/news/latest/post/168-aac-publishes-updated-cl... [Accessed February 2023].
- INC-DOF-014.
- Abner S et al. Cardiovasc Diabetol 2022;21(1):8.