Tips for effective lipid management consultations for secondary prevention of cardiovascular disease

Introduction

An estimated 7.5 million individuals in the UK are living with heart and circulatory diseases. Deaths associated with these conditions account for nearly one-quarter (26%) of all deaths, meaning they are the second leading cause of death in the UK^​1​. Around 49,000 of these deaths occur in individuals under the age of 75 years, highlighting the importance of implementing secondary cardiovascular disease (CVD) prevention strategies to mitigate mortality associated with CVD — particularly in light of the ageing UK population. Projections published by the British Heart Foundation (BHF) in January 2025 indicate that an additional 1 million individuals will be living with heart and circulatory diseases by 2030^​1​.

CVD is a leading cause of morbidity, disability and health inequalities, costing the NHS up to £7.4bn annually^​2​. CVD prevention is included in the Core20Plus5 initiative, which addresses^​3​ healthcare inequalities — particularly in relation to hypertension case finding and optimal lipid management^​3​. Effective lipid management is essential for reducing the risk of further CVD events in patients with an established history of CVD.

Pharmacists and pharmacy teams play a vital role in supporting adherence to lipid profile targets for secondary prevention. Their expertise allows them to engage in discussions with patients about the importance of lipid-lowering therapy optimisation. Pharmacy technicians can help identify patients with out-of-target lipid profiles and ensure timely blood monitoring. In addition, pharmacy technicians conduct initial consultations with patients regarding having their current lipid lowering therapy optimised or new therapies commenced. Community pharmacies contribute by promoting lifestyle changes and discussing lipid-lowering therapies with patients, as well as providing locally commissioned phlebotomy services to facilitate blood monitoring.

Patients with a known history of CVD are at the highest risk for further events and mortality. This article will focus on secondary prevention for patients with a confirmed history of CVD and how pharmacists can have effective lipid management consultations. 

Background

According to National Institute for Health and Care Excellence (NICE) guidance, published in 2023, patients should maintain low-density lipoprotein cholesterol (LDL-C) levels below 2.0 mmol/L or non-HDL cholesterol below 2.6 mmol/L for the secondary prevention of CVD^​4​. Local guidelines may set more stringent targets, as determined by specialist teams. Elevated levels of LDL-C and non-HDL-C, which are often referred to as ‘bad cholesterol’ during consultations with patients, can contribute significantly to plaque buildup in arteries, increasing the risk of narrowing arteries, heart attacks and strokes — especially in patients with a history of CVD.

Many patients with a history of CVD and elevated lipid profiles are asymptomatic, which further emphasises the importance of completing periodic lipid profile monitoring. Primary and secondary care teams should be consulting with these patients regarding effective methods to manage lipid levels, including medication optimisation and initiation of new therapies, while continuing to encourage positive lifestyle changes that reduce CVD risk.

Regular monitoring of lipid profiles in high-risk patients is crucial for reducing the risk of mortality and recurrent myocardial infarction. Each 1 mmol/L reduction in LDL-C is associated with a 22% decrease in major vascular events after one year^​5​.

According to NHS England data, as of March 2023, 82.2% of patients with recorded CVD are being treated with lipid-lowering therapy. If treatment rates increase to 90%, nearly 14,000 heart attacks, strokes and deaths could be prevented within three years, while a rise to 95% could prevent around 22,000 events^​2​. Coronary heart disease (CHD) death rates are highest in Scotland, with 28% of all deaths being attributed to CVD, which is nearly 50 deaths per day^​6​ (18). In Wales, around 340,000 people are living with CVD, with 27% of all deaths being attributed to the condition, which is an average of 27 deaths per day^​7​. 

Data as of March 2025 shows that patients with GP-recorded CVD have a national average treatment rate of 85.53% for lipid-lowering therapy, with the lowest being in the south west of England (83.65%) and the highest in the Midlands (86.5%). However, only 48.25% of these patients have LDL-C levels ≤ 2.0 mmol/L or non-HDL cholesterol ≤ 2.6 mmol/L, indicating that nearly half are at increased risk for further CVD events. The south east of England has the lowest compliance at 44.3%, while the north east of England and Yorkshire have the highest at 51.58%^​8​.

Factors affecting therapeutic compliance

There are several factors that can affect a patient’s willingness to start and adhere to lipid therapy. It is crucial for healthcare professionals to identify these factors and facilitate open discussions with patients to overcome any barriers. This collaborative approach allows for the development of tailored management plans, enhancing the likelihood of achieving desired health outcomes and reducing the risk of secondary CVD events.

Concerns regarding side effects and negative perceptions of therapies, particularly statins, can deter patients from initiating or continuing treatment^​9​. Addressing patients’ hesitance toward treatment can be a common challenge during consultations. The following considerations can reassure patients and contribute to effective lipid consultations:

• Providing patients with comprehensive information on lipid-lowering therapies prior to consultations is essential for informed decision-making. This information, which is available on the British Heart Foundation website, should include the benefits of these therapies, a detailed explanation of how the medications work and relevant information regarding the potential side effects associated with various lipid-lowering treatments;
• Building familiarity with patients can lead to improved relationships and enhance shared decision-making, supporting medication concordance and compliance;
• Open discussions about medication side effects can increase patients’ confidence in lipid-lowering therapies. Concerns about side effects are common, and many patients will have read information online or may know people who have experienced side effects when starting lipid-lowering therapies. Reassurance can be provided explaining to patients that there are well-established protocols for managing side effects (e.g. statin intolerance protocols), ensuring that patients know they will not be left unsupported once treatment starts. This consideration is essential for building trust and long-term adherence;
• Communicating the risks associated with elevated lipid profiles is imperative for obtaining informed consent from patients who decline treatment. Globally, one-third of ischemic heart disease is attributable to high cholesterol, resulting in around 2.6 million deaths annually^​10​. Many patients remain unaware of the risks of further CVD events associated with elevated lipid levels and do not understand the seriousness of optimising their lipid-lowering therapies. Communicate health risks non-judgmentally by using empathetic language, focusing on education and collaboration, encouraging questions and personalising the conversation to support the patient’s health goals;
• Some treatment options may not be suitable for all patients. For example, the addition of ezetimibe may increase the pill burden, which may be unacceptable to patients who already have complex medication regimens^​11​;
• Follow-up appointments can further reinforce the patient’s understanding of their condition and improve confidence in treatment decisions. Pharmacists, particularly those in practice-based settings, play a pivotal role in this educational process.

Supporting adherence

Factors influencing adherence can vary significantly and may be impacted by local population deprivation and social determinants, such as ethnicity, which contribute to health inequalities. In the UK, over 40% of adults demonstrate low health literacy and struggle with health information, particularly content involving numbers and statistics^​12​. This lack of understanding can hinder patients’ ability to engage in informed decision-making regarding their lipid-lowering therapies. This can be addressed during consultations through the use of visual aids, employing the teach-back method, encouraging questions and providing tailored support, while creating an empathetic and open environment.

For patients already on lipid-lowering medications, it is essential to assess adherence before discussing further treatment options. A review of English primary care data, published in 2025, showed that out of 337,990 individuals prescribed statins, 32.9% had suboptimal adherence^​13​. It is important for patients to understand that lipid-lowering therapies are intended for long-term use and should not be discontinued once target lipid levels are achieved. Educating patients about the necessity of ongoing therapy can reinforce the importance of adherence in reducing the risk of secondary CVD events.

The increasing interest in complementary and alternative medicine (CAM) necessitates awareness of potential interactions. For example, St. John’s Wort can significantly reduce the effectiveness of statins. In 2014, the Medicines and Healthcare products Regulatory Agency estimated that 26% of adults have taken herbal medicines in the past two years^​14​. It is vital to establish whether patients are using CAM and provide evidence-based information about conventional therapies to enable them to make a well-informed decision about their treatment. This is particularly important for patients who decline lipid-lowering medications. Conversations should be approached respectfully and in a non-judgmental way, with the pharmacist actively listening, asking open-ended questions and providing evidence-based information, while respecting their individual autonomy. It is also important to avoid assumptions, encourage open dialogue and remain supportive throughout the discussion. 

If patients express interest in non-medical approaches to lipid management, the opportunity should be taken to emphasise the importance of lifestyle changes including increased exercise, improvements to diet and smoking cessation and signposting to sources of additional information and support where appropriate. Lifestyle modifications are not only crucial for reducing the risk of further CVD events but also for preventing other long-term conditions such as diabetes. Pharmacists can provide lifestyle counselling during consultations and distribute educational materials, including leaflets, videos and digital resources. Utilising technology, such as secure messaging systems, can further enhance patient access to these materials — for example, information sheets available in different languages as available on the BFH website^​15​.

Optimising the consultation

It can be beneficial to adopt a structured approach to consultations, employing established models such as ‘Ideas, Concerns and Expectations’ (ICE), the Calgary–Cambridge model and COG Connect. These approaches can optimise interactions and ensure that all relevant information is conveyed efficiently^​16​.

The case example below illustrates how the ICE consultation model can be used when discussing initiation of lipid lowering therapies for secondary CVD prevention. 

Strategies to optimise services

Practice-based pharmacists are ideally positioned to manage patients with out-of-target lipid profiles. General practitioners can refer such patients to pharmacists for dedicated discussions about treatment options, while pharmacists can also address these patients opportunistically during medication reviews and other consultations. This flexibility accommodates patients who may have scheduling conflicts with traditional lipid-lowering clinic sessions. 

Addressing barriers to blood monitoring is also essential for effective lipid management, especially for patients with personal or work commitments that limit their availability. Implementing ad hoc phlebotomy sessions within primary care networks or utilising community pharmacies with extended hours can help facilitate necessary blood tests. The recent emphasis on lipid management, as outlined in the NHS’s priority objectives as mentioned previously in the Core20PLUS5, further illustrates the need to address knowledge gaps within primary care related to the management and prescribing of lipid-lowering therapies. 

To effectively address the risks of CVD in patients with elevated lipid profiles, a standardised and consistent approach should be implemented within general practices. Knowledge gaps can be addressed through educational sessions designed to enhance the competence of all members of the multidisciplinary team (MDT) in general practices. There is a significant opportunity for pharmacists to lead and deliver this work. Establishing a standardised internal protocol for lipid management will ensure that these patients receive consistent care in accordance with the latest guidelines and most appropriate medicines.

Services can be further optimised through effective collaboration with local specialist pathology for management of complex lipid profiles. For instance, a small subset of patients may not achieve target lipid levels with inclisiran, possibly owing to polymorphisms of the asialoglycoprotein receptors^​17​. Such patients may require referral to local pathology for evaluation of other treatments, such as PCSK9 inhibitors, if other conventional therapies have been ineffective or unsuitable. Working closely with specialist services in this way can further reduce unnecessary referrals to secondary care and improve compliance with CVD secondary prevention targets.

Healthcare professionals, including pharmacists, must prioritise transparency with patients when there is clinical uncertainty around identifying the most appropriate treatment option. This includes discussing the associated risks, such as side effects, and benefits to support the best choice of therapy for each patient. Prioritising these discussions can also help reduce the risk of further cardiovascular events, such as LDL-C reduction potency. For example, if atorvastatin is not tolerated, alternative options such as rosuvastatin or bempedoic acid can be considered.

Where uncertainty exists, it is good practice to seek specialist advice enabling an informed and shared decision to be made with the patient. This approach can enhance patient trust and help to foster a collaborative healthcare environment that makes full use of the skill mix with the MDT.

It is important to acknowledge a potential lack of confidence among prescribers — including doctors, pharmacists, and nurses — in regard to lipid management and the prescription of novel lipid-lowering therapies that can be used in primary care, such as inclisiran and bempedoic acid. A study conducted by the University of Birmingham, published in 2024, highlights that participants expressed feelings of inexperience with these therapies, reinforcing the need for ongoing continual professional development as these newer treatment options become more established within primary care^​18​.

Conclusion

Effective lipid management is crucial for preventing CVD, which significantly impacts mortality rates in the UK. Pharmacists play a vital role in this process by educating patients, addressing adherence barriers and developing tailored treatment plans. Regular follow-ups and clear communication foster patient engagement and ensure comprehensive care. By staying informed about current therapies, novel treatments and the latest guidelines, pharmacists can enhance patient outcomes, empowering individuals in their health journeys, while contributing to a reduction in the burden of CVD. A collaborative, person-centred approach not only improves adherence to lipid-lowering therapies but also strengthens the pharmacist-patient relationship, ultimately leading to better health outcomes for patients at risk of CVD.