Quality Prescribing Guidance for Cardiovascular Risk Reduction 2026-2029

The consultation questions are included here for your reference. Please click 'Begin consultation' at the bottom of this page to proceed.

1. Approach to review

We recommend for all patients, medications are reviewed using a person-centred approach using the standardised Polypharmacy 7-Steps guidance. 

Question 1a

Do you agree with this recommendation?         

Question 1b

Please tell us more about your views on our approach to review.

2. Use of ASSIGN v2.0

• ASSIGN v2.0 (ASsessing cardiovascular risk using SIGN guidelines to assign preventive treatment) should be used to estimate the 10-year percentage risk of developing cardiovascular disease (coronary heart disease, stroke, and transient ischaemic attack) of individuals in Scotland who do not currently have a diagnosis of cardiovascular disease
• In some ethnic minorities, risk tools under- and overestimate CVD risk, because they have not been validated in these populations. For example, in people originating from the south Asian subcontinent it is safest to assume that the CVD risk is modestly higher than predicted from most scoring tools
• The following individuals should be assumed to be at high risk and do not require risk assessment with ASSIGN v2.0 or other cardiovascular risk scoring systems:

• Chronic Kidney Disease Estimated Glomerular Filtration Rate (CKD eGFR) <60 or Albumin-to-Creatinine Ratio (ACR) >3mg/mmol (approx. equal to 30mg/g)
• Familial hypercholesterolaemia (FH) 
• Type 1 diabetes who are over 40 years old, or disease duration >10 years, or nephropathy or other CVD risk factors

Question 2a

Do you agree or disagree with these recommendations on the use of ASSIGN v2.0?

Question 2b

Please provide any further comments about our recommendations.

3. Healthier Lifestyle

Diet

• Increased fruit and vegetable consumption is recommended for the entire population to reduce cardiovascular risk
• People with hypertension should be advised to reduce their salt intake as much as possible to lower blood pressure
• Eating a portion of oily fish (such as salmon and trout) each week can also help to lower the risk of developing heart disease
• Individuals are encouraged to follow the advice in NHS inform Eat Well Guide which helps support individuals to make healthier food choices

Alcohol

• Patients with or without evidence of cardiovascular disease should be advised to reduce alcohol consumption and that even light to moderate alcohol consumption may increase cardiovascular risk

Physical Activity

• Physical activity of at least moderate intensity is recommended for the whole population (unless contraindicated by an individual’s condition)
• Those who are moderately active and are able to increase their activity should be encouraged to do so. Activity can be increased through a combination of changes to intensity, duration or frequency.

Those who are already moderately active without contraindication can safely be encouraged to undertake vigorous-intensity exercise to achieve additional benefits

Question 3a

Do you agree or disagree with these recommendations on healthier lifestyle?

Question 3b

Please provide any further comments about our recommendations.

4. Hypertension in adults

• Hypertension in adults should be diagnosed and treated as per National Institute for Health and Care Excellence (NICE) 136
• Individuals should be identified who need referred for same-day specialist review as per NICE 136
• People with hypertension should be advised to reduce their salt intake as much as possible to lower blood pressure
• When choosing an antihypertensive medication, the individual should be part of the decision-making. Discuss individual cardiovascular disease risk and the individual’s preferences for treatment, including no treatment, and explain the risks and benefits before starting antihypertensive drug treatment
• A suitable algorithm such as NICE or the British and Irish Hypertension Society (BIHS) adult hypertension referral pathway for therapeutic management should be utilised when choosing an antihypertensive medication considering the individual's age, family origins and co-morbidities
• Clinical judgement and shared decision-making should be used when prescribing in individuals with frailty or multimorbidity

Question 4a

Do you agree or disagree with the recommendations for hypertension in adults?

Question 4b

Please provide any further comments about our recommendations.

5. Hyperlipidaemia

• Non-fasting sampling of lipid parameters is recommended for general risk screening
• Measure both total blood cholesterol and high-density lipoprotein (HDL) cholesterol to achieve the best estimate of CVD risk
• Primary prevention using a statin is recommended in individuals with:

• ASSIGN v2.0 score ≥10%
• CKD eGFR <60 or ACR >3mg/mmol (approx. equal to 30mg/g)
• Familial hypercholesterolaemia (FH)
• Type 1 diabetes who are over 40 years old, or disease duration >10 years, or nephropathy or other CVD risk factors

• Atorvastatin 20mg daily is the statin of choice in primary prevention
• Consider ezetimibe
  • where initial statin therapy is contraindicated or individuals cannot tolerate statin therapy
  • co-administered with initial statin therapy when Serum total or Low-density Lipoprotein (LDL) cholesterol concentration is not appropriately controlled or a change from initial statin therapy to an alternative statin is being considered
• If treatment is initiated, its effect must be evaluated, and subsequent treatment intensification to reach ultimate risk factor goals must be considered in all patients, taking into account additional benefit, comorbidities, and frailty, all of which converge with patient preferences in a shared decision-making process.
• The absolute benefit of lowering Low-Density Lipoprotein Cholesterol (LDL-C) depends on the absolute risk of Atherosclerotic Cardiovascular Disease (ASCVD) and the absolute reduction in LDL-C, so even a small absolute reduction in LDL-C may be beneficial in a high- or very-high-risk patient

Question 5a

Do you agree or disagree with the recommendations for hyperlipidaemia?

Question 5b

Please provide any further comments about our recommendations.

6. Pharmacotherapies for obesity

We recommend that clinicians:

• Ask for permission each time before discussing overweight, obesity or central adiposity and before taking measurements
• In adults with Body Mass Index (BMI) below 35 kg/m2, measure and use their waist-to-height ratio, as well as their BMI, as a practical estimate of central adiposity and use these measurements to help to assess and predict health risks (for example, type 2 diabetes, hypertension or cardiovascular disease)
• Incretin-based therapies should be considered for those who meet Scottish Medicines Consortium (SMC)/consensus statement criteria

Question 6a

Do you agree or disagree with the recommendations for pharmacotherapies for obesity?

Question 6b

Please provide any further comments about our recommendations.

7. Diabetes

• Primary care healthcare professionals should implement a two-stage strategy to identify people at high risk of type 2 diabetes (and those with undiagnosed type 2 diabetes)

• Firstly, a risk assessment should be offered
• Secondly, for those with high-risk scores, a blood test should be offered to investigate if they have type 2 diabetes or prediabetes

• Reassess people with a high-risk score, but with a Glycated Haemoglobin (HbA1c) less than 42mmol/mol (6.0%) or a fasting plasma glucose less than 6.1mmol/L or, every three years
• Reassess people with a low or intermediate risk score every five years using a validated risk-assessment tool
• Use clinical judgement to determine when someone might need to be reassessed more frequently, based on their combination of risk factors

• Metformin should be considered as the first-line oral treatment option for people with type 2 diabetes
• NICE 28 flowchart should be utilised when choosing medication considering the individual's cardiovascular status, risk of developing cardiovascular disease in the future, renal status and if considered clinically significantly frail

Question 7a

Do you agree or disagree with the recommendations for diabetes?

Question 7b

Please provide any further comments about our recommendations.

8. Smoking

• All people who smoke should be advised to stop and offered support to help facilitate this in order to minimise cardiovascular and general health risks
• At every opportunity, ask people if they smoke or have recently stopped smoking
• Varenicline or combination nicotine replacement therapy should be offered alone or as part of a smoking cessation programme to augment professional advice and increase long-term abstinence rates

Question 8a

Do you agree or disagree with the recommendations for smoking?

Question 8b

Please provide any further comments about our recommendations.

9. Effectiveness of these recommendations

Question 9

How effective do you think these recommendations will be in reducing CVD?

10. Implementation of this guidance

We have a few questions, which will help us implement the recommendations from this prescribing guide.

Question 10a

Do you feel there are any barriers to implementing the recommendations from this guidance?

Question 10b

If you answered yes to Question 10a, how do you feel these barriers could be addressed?

Question 10c

What are the key factors that will enable successful implementation of these recommendations?

11. Finally

Question 11

Do you have any further comments on this prescribing guide?