How should I assess cardiovascular risk in a patient with elevated cholesterol levels?

Assess cardiovascular risk in a patient with elevated cholesterol levels by following these steps:

• Use a systematic approach to identify people likely to be at high risk of cardiovascular disease (CVD), prioritising those with an estimated 10-year CVD risk of 10% or more for a full formal risk assessment. This can be initially estimated using existing CVD risk factors recorded in primary care electronic medical records ¹.
• Perform a full formal risk assessment using the QRISK3 tool for people aged 25 to 84 years without established CVD, including those with type 2 diabetes. QRISK3 accounts for additional risk factors such as corticosteroid use, severe mental illness, and systemic lupus erythematosus, which may underestimate risk if using QRISK2 ¹,³.
• Before risk calculation, measure a full lipid profile including total cholesterol, HDL cholesterol, and triglycerides to calculate non-HDL and LDL cholesterol. A fasting sample is not mandatory ³.
• Use clinical findings, lipid profile results, and family history to assess the likelihood of familial hypercholesterolaemia (FH) rather than relying on strict lipid cut-offs alone. Exclude secondary causes of dyslipidaemia such as excess alcohol intake, uncontrolled diabetes, hypothyroidism, liver disease, and nephrotic syndrome before referral or treatment decisions ¹,³.
• Do not use QRISK3 for people at very high risk such as those with type 1 diabetes, CKD (eGFR <60 ml/min/1.73m2 or albuminuria), or familial hypercholesterolaemia; these groups require specialist assessment and may be offered statins without formal risk scoring ¹,²,³.
• Discuss the process and implications of risk assessment with the patient, including lifestyle modification advice and the option to decline formal assessment ¹,³.

Summary: Assess cardiovascular risk in patients with elevated cholesterol by measuring a full lipid profile, excluding secondary causes, using QRISK3 for formal 10-year risk estimation in appropriate patients, and considering familial hypercholesterolaemia and other high-risk conditions separately. This approach guides decisions on lifestyle advice and statin therapy ¹,²,³.