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You are here: Home / Resources / Lipids, FH and PCSK9i / Lipids, Familial Hypercholesterolaemia (FH) and PCSK9i Guide for SystmOne

Lipids, Familial Hypercholesterolaemia (FH) and PCSK9i Guide for SystmOne

Searches:

Searches beginning “!” or “?” are key reports for clinical teams to consider running. These can be found by sorting the searches by name.


A suite of searches for SystmOne, created by the Clinical Digital Resource Collaborative (CDRC) can be used to identify patients to review with regards lipid optimisation and identification of patients with possible FH. Searches are organised into tiers to allow for manageable numbers of patients depending on the resource you have available. To find out more, please visit the facts.cvd website.

Tiers 1 & 2: Lipids Optimisation
  • People who need their lipid therapy to be considered for very high intensity
  • People prescribed a statin but not taking it
  • People with a history of a previous CVD event i.e. for secondary prevention but not prescribed lipid lowering therapy
  • Those with a CVD risk greater than 20% who have not had a risk assessment
  • People with a Q-risk greater than 10% but not prescribed lipid lowering therapy
  • People with an estimated QRISK >10% who are not currently eligible for NHS Health Check and do not have a Long Term Condition (LTC).
Tier 3: FH
  • People with suspected FH
  • People who may need specialist lipid input such as requiring a PCSK9 inhibitor or potential contra-indication regarding statin therapy.

Please contact contact-CDRC@ahsn-nenc.org.uk  to register your interest, and if you need help with searches/ templates.

SystmOne Guidance: Lipids & Familial Hypercholesterolemia:

The information below is designed to support users to access CDRC searches and reports via SystmOne in line with the facts.cvd Standard Operating Procedure. For additional guidance, please watch the tutorial video below.

1.1 Run case finding searches

The following sets of searches will help identify patients with uncoded conditions which will affect decisions about lipid modification. 

Case Finding (Cardiology) – uncoded CHD, AF 

Case Finding (Renal) – uncoded CKD 

Case Finding (Neurology) – uncoded stroke / TIA or unclassified stroke types 

Case Finding (Vascular) – uncoded PAD 

The following report may also identify patients with uncoded atherosclerotic disease: 

CDRC Quality > Cardiovascular>? Drug to Diagnosis 003 – Antiplatelets without obvious indication 

1.2 Identifying patients who are likely to need to be offered lipid modification

The following searches will identify people who might benefit from lipid modification based on information in the record which suggests they have a clear indication. 

Search Location  Notes 
? LIPID 3.0 Management – Consider Lipid Lowering # CDRC Quality – Lipids Patients who appear eligible for lipid lowering for primary or secondary prevention who haven’t got a recorded reason why not. Review patient – consider offering statin, recording ‘declined, not indicated’ etc, recording previous ADRs to lipid lowering treatment. This search has child searches which risk stratify patients so those at highest risk can be prioritised (3.01-3.06) 

Patients in LIPID 3.0 will have the following patient status alert to prompt the clinician to consider discussing statins.  

High CVO Risk - Consider Lipid Lowering 
High CVD risk but not on lipid lowering treatment

 Clicking the PSA will open the Lipid Details template. 

They will also have a prompt to consider lipid lowering on the LTC management system and a prompt to consider checking LFTs/lipids if the patient would consider lipid lowering. 

Check 
Check LipidsA_FTs 
if would consider stati 
Check Hba lc 
Check ACR 
Consider Lipid Lowering
 1.3 Identifying patients with poor concordance for lipid modification 

The following search will identify people who do not appear to be taking lipid lowering medication which is on repeat 

Search Location  Notes 
? Lipids 3.2 Management – Possible poor lipid lowering therapy concordance # CDRC Quality – Lipids Patients with repeat lipid lowering therapy who have not been issued a prescription in the last 3 months Review patient – discuss concordance or remove medication from repeat if no longer necessary 

The LTC Master template and Lipid Details template will display a warning about concordance. 

Check FBC 
Check Hba lc 
Check ACR 
Consider Hypertension 
CONSIDER LOW LIPID LOWERING CONCORD
Calculate Target Non HDL-C 
Target Non HDL-C 
Statin offered 
Statin declined 
Statin not indicated 
NO cholesterol target recorded 
Current Lipid Medication 
Atorvastatin 20mg tablets 
2g Dec 
take 28 ta 
CONSIDER LOW LIPID LOWERING CONCORDANCE 
07 Jan 2011 statin not indicated rxallg) (SNOMED: 1343g1 005) 
A Medication Timeline 
Resu!ts Vpid 
A Expand 
Notes 
doesnt want thenm

The Medication Timeline and Lipid Results with Lipid Rx buttons can be used to examine concordance in more detail 

ASPIRIN 
CLOPIOOGREL 
SILOENAFIL
Atorvastatin 20mg tablets 
Atorvastatin 20mg tablets 
Atorvastatin 20mg tablets 
Atorvastatin 20mg tablets 
Atorvastatin 20mg tablets 
Atorvastatin 20mg tablets 
Atorvastatin 20mg tablets 
Atorvastatin 20mg tablets 
Atorvastatin 20mg tablets 
Atorvastatin 20mg tablets 
Atorvastatin 20mg tablets 
take one daily 
take one daily 
take one daily 
take one daily 
take one daily 
take one daily 
take one daily 
take one daily 
take one daily 
take one daily 
take one daily 
05 Mar 2018 
04 dun 2018 
31 dui 2018 
27 Dec 2018 
23 Apr 201 g 
27 Aug 201g 
dan 2020 
13 2020 
lg Mar 2020 
16 dun 2020 
22 dui 2020 
04 sep 2020 
04 sep 2020 
04 sep 2020 
04 sep 2020 
7 Oct 2020 
07 Oct 2020 
07 Oct 2020 
07 Oct 2020 
serum HDL cholesterol level (4495) (SNOMED: 1 005681 0000001 07) 
Serum non high density lipoprotein cholesterol level [XabE1) (SNOMED: 
serum cholesterol level (SNOMED: 1 005671 0000001 05) 
serum LDL cholesterol level (44P6J (SNOMED: 1 0221 gl 0000001 00) 
Serum non high density lipoprotein cholesterol level [XabE1) (SNOMED: 
serum LDL cholesterol level (44P6J (SNOMED: 1 0221 gl 0000001 00) 
serum HDL cholesterol level (44P5J (SNOMED: 1 005681 0000001 07) 
serum cholesterol level (SNOMED: 1 005671 0000001 05) 
10061 glo 
10061 glo 
2f mmol/L 
2 mmol/L 
4f mmol/L 
1 7 mmol/L 
24 mmol/L 
21 mmol/L 
2G mmol/L 
4 F mmol/L 
Atorvastatin 20mg tablets 
Atorvastatin 20mg tablets 
take one daily 
take one daily 
23 Oct 2020 
Dec 2020
1.4 Optimising lipid modification 

The following searches will identify patients who may need lipid modification optimisation 

Search Location  Notes 
? Lipids 4.1 Management – On lipid lowering – without a lipid target # CDRC Quality – Lipids Patients with repeat lipid lowering therapy who do not have a lipid target Review patient – consider adding target.  The Lipid Details Template  will facilitate this 
? Lipids 4.2 Management – On lipid lowering – has lipid target but not achieved # CDRC Quality – Lipids Patients with a lipid target which has not been achieved Consider intensification of lipid treatment or relaxation of target (e.g. for frail patients) 
? Lipids 4.3 Management – On low/mod lipid lowering – consider intensification # CDRC Quality – Lipids Patients on moderate or low potency lipid lowering without a documented reason. Review patient.  Consider:  
– Intensification 
– coding of previous ADRs to lipid lowering 
– recording patient has reached maximally tolerated lipid lowering. 
– Loosen target cholesterol 
? Lipids 4.31 Management – On low/mod lipid lowering – consider intensification (excl. target is achieved) CDRC Quality – Lipids As for 4.3 but excludes patients who have reached their target cholesterol As above 
? Lipids 4.4 Management – Consider intensification to very high intensity lipid lowering # CDRC Quality – Lipids Patients eligible for secondary prevention who are not on very high intensity lipid lowering Review patient.  Consider  
– Intensification 
– coding of previous ADRs to lipid lowering 
– recording patient has reached maximally tolerated lipid lowering. 
– Loosen target cholesterol 
? Lipids 4.41 Management – Consider intensification to very high intensity lipid lowering (excl. target is achieved) # CDRC Quality – Lipids As for 4.4 but excluding patients who have reached their target cholesterol As above 
? Lipids 4.5 Management – Consider intensification for patients with ASCVD and non-HDLC >=2.5 CDRC Quality – Lipids Patients with established atherosclerotic ASCVD with nonHDL C unless they have achieved a stated target – Review patient.  Consider  
– Intensification coding of previous ADRs to lipid lowering 
– recording patient has reached maximally tolerated lipid lowering. 
– Loosen target cholesterol 

Patients found in searches 4.1, 4.2, 4.3 and 4.4 will have prompts displayed on the Lipid Details and LTC Master template: 

Lipids Lipid Results 
Lipids 
Q 
QRISK2 calculator 
08 
Lipid Targets Exceptions 
NICE Lipid Pathway 
FH Screening References Lipids (legacy) 
Has manifest atherosclerosis SECONDARY PREVENTION usually recommended 
QRlSK2 
25 
16 Aug 2016 
Dec 2020 
08 Dec 2020 
8 Dec 2020 
08 Dec 2020 
8 Dec 2020 
Dec 2020 
QRlSK2 cardiovascular disease 10 year risk 25t3 % 
serum HDL cholesterol level (44P5J (SNOMED„ mmoI/L 
serum triglyceride levels (SNOMEO: 10 mmoI/L 
Serum non high density lipoprotein cholesterol mmol/L 
serum cholesterol level 10 mmoI/L 
serum LOL cholesterol level (4496) (SNOMEDL mmoI/L 
Target serum non high density lipoprotein cholest.„ mmol/l 
Lipid Targets 
Over the counter statin therapy 
Lipid Lowering Medication 
Rosuvastatin 5mg tablets og Mar take tm 
Lipid target NOT achieved 
Consider lipid lowering intensification 
Consider very high intensity lipid lowering 
(31
Core Data 
aronchiectasis 
copo 
Pulm Fibrosis 
CHO 
Hean Failure 
BP Hypertension 
PAD OCS 
Stroke Dcs 
dl 
Diabetes 
High Risk of DM 
Hypothyroidism 
NAFLD 
Epilepsy 
Dementia 
a Mental Heath 
C Palliative Care 
Is a Carer 
Check 
Year of Care 
Lipid target NOT achieved 
Consider lipid lowering intensification 
Consider very high intensity lipid lowering
1.5 More Specialist Lipid Management 

The following searches will identify patients who may need more specialist input 

Search Location  Notes 
PCSK9i Treatment    
? Lipids 5.1 Management – Consider lipid lowering – May need more detailed input CDRC Quality – Lipids Patients who appear to need lipid lowering but have had ADR to at least one statin AND ezetimibe – may need specialist input  
? Lipids 5.2 Management – Referral criteria for PCSK9i but poor concordance with current treatment CDRC Quality – Lipids Fulfil referral criteria for PCSK9i therapy but may not be taking current lipid lowering therapy Review concordance 
? Lipids 5.3 Management – Referral Criteria for PCSK9i – Consider primary care intensification CDRC Quality – Lipids Fulfil referral criteria for PCSK9i therapy but there may be scope for intensification of lipid lowering therapy in primary care Review record 
? Lipids 5.4 Management – Referral Criteria for PCSK9i – Consider referral ** CDRC Quality – Lipids Likely to be eligible for PCSK9i referral Consider referral 
Familial Hypercholesterolaemia    
? Lipids 2.0 Case Finding – Consider screening for familial hypercholesterolaemia ** CDRC Quality – Lipids Patients at high chance of having familial hypercholesterolaemia Review record 

** Patients will be excluded from these searches for 5 years is the questionnaire on the lipid review is completed. 

Patients in 5.4 will have a prompt displayed on the Lipids Details and LTC Master templates: 

Lipids 
Q QRlSK2 Calculator 
QRlSK2 
Lipid Targets 
NICE Lipid Pathway 
Over the counter statin therapy 
Lipid Lowering Medication 
Lipid Exceptions 
Lipid Lowering Declined 
Lipid Lowering Not Indicated 
On max tolerated lipid lowering 
Has manifest atherosclerosis SECONDARY PREVENTION usually recommended 
Has record of DEFINITE FAMILIAL HYPERCHOLESTEROLAEMIA 
CVD Risk Numeric NOT recorded 
10 Nov 2020 serum HDL cholesterol level (44P5J (SNOMECI 
1M mmol/L 
10 Nov 2020 serum triglyceride levels (SNOMEO: 10 
2Æ8 mmol/L 
10 Nov 2020 Serum non high density lipoprotein cholesterol In 5Æ mmol/L 
10 Nov 2020 serum cholesterol level (SNOMEO: 10 
7 mmol/L 
10 Nov 2020 serum LDL cholesterol level (4496) (SNOMED 
4f mmol/L 
NO cholesterol target recorded 
Rosuvastatin 20mg tablets 08 Mar ONE„ 28 tm 
! CONSIDER REFERRAL FOR PCSK9 INHIBITOR 
Consider adding lipid target 
RECORD of ADR to ezetimibe 
RECORD of ADR to statin(s) 
26 Jan 200g 
Patient on maximal tolerated lipid lowering therapy (Xad5i) (SBC 
Notes 
see letter 2004
Page 4 Home LettersjAppts 
HOC 
Core Data 3ntry% 
aronchiectasis 
copo 
Pulm Fibrosis 
CHO 
Hean Failure 
BP Hypertension 
PAD OCS 
Stroke Dcs 
Diabetes 
High Risk of DM 
Hypothyroidism 
O CKD 
NAFLD 
Page 5 
Epilepsy 
Dementia 
a Mental Heath 
C Palliative Care 
Is a Carer 
Check FBC 
Check 
Check LFTS 
Check AST 
Check GammaGT 
Check Lipids 
Check Hba lc 
Check ACR 
Year of Care 
Consider Shingles Vaccination 
Consider Frailty 
! CONSIDER REFERRAL FOR PCSK9 INHIBITOR 
Consider adding lipid target
1.6 Identifying Patients To Be Offered a CVD Risk Assessment 

NICE guidance indicates that patients with an estimated CVD risk >=10% (i.e. based on the information currently available in the record) should be offered a formal CVD risk assessment.  The following searches identify such patients 

Search Location  Notes 
? Lipids 1.0 Screening – Target for CVD Risk Assessment (as estimated risk is >10%) CDRC Quality – Lipids Patients whose estimated CVD risk is >10%. Excludes: 
– On lipid lowering therapy 
– Recorded reason why lipid lowering therapy not being taken 
– Established CVD or FH 
Consider offering these patients a CVD risk assessment 
? Lipids 1.01 Screening – Target for CVD Risk Assessment – eligible for NHS HC CDRC Quality – Lipids Patients in 1.0 who are currently eligible for and NHS Health Check Consider offering NHS Health Check 
? Lipids 1.02 Screening – Target for CVD Risk Assessment – has LTC CDRC Quality – Lipids Patients in 1.0 who also have a long term condition Consider offering CVD risk assessment at next LTC review 
? Lipids 1.03 Screening – Target for CVD Risk Assessment – not eligible for NHS HC, no LTC CDRC Quality – Lipids Patients in 1.0 who do not have a long term condition and who are not currently eligible for an NHS Health Check Consider specific invitation for CVD risk assessment 
? Lipids 1.04 Screening – Target for CVD Risk Assessment – estimated risk >20% CDRC Quality – Lipids Patients in 1.0 who have an estimated CVD risk >=20% Consider prioritising these patients for CVD risk assessment 

Additional Information

1. How can the resources help me to manage my patient’s lipids?

The main lipids template gives an overview of all relevant results, medication history, patient decision aids and quick-access buttons to record frequently-required actions:

Lipid Details 
Other Details 
Exact date & time • 
10 Mar 2020 
Lipids Exceptions References 
Total Choi 
Not r4 
LDL Choi 
Not r4 
21 
HDL Choi 
ot r4 
Non HDL Choi 
Not r4 
5 issues 
A Triglycerides 
Not r4 
A QRlSK2 
Not r4 
Expiring Lipid Exceptions 
Persistent Lipid Exceptions 
Current Lipid Medication 
Previous Lipid Drugs 
e Atorvastatin 20mg tablets 
aRlSK2 calculator 
011 Lipid Narrative 
Patient Decision 
Starting a Statin 
Calculate or record target non-HDLC 
Add Schd taskfor lipids and IRS in 3m 
Consider PIL (print or email) 
03 Jan 201g 
Meds Overview 
PIL Statin Patient Decision Aid 
Exceptions 
DCS Lipid Narrative view has no data for patient 
Statin offered 
Statin declined 
Statin not indicated 
Statin Cates Plot 
New repeat of Atorvastatin 20mg tabl 
Calculate Target Non HDL Chol 
New Scheduled Task 
PIL Statin 
New Repeat Template 
Target Non HDL Cholesterol 
NICE Lipid Pathway 201 a

The ‘Meds Overview’ button gives a timeline of medications so the clinician has an overview of what the patient has had before, what they are on now and concordance:

Action Group Timeline 
- 
u11B Aug 1B 
oa Aug 201B 
Settings 
Cardiovascula 
ASPIRIN 
ATENOLOL 
ATORVASTATIN 
CINNARIZINE 
GLYCERYL TRINITRATE 
RAMIPRIL 
ntral nervous 
Respiratory 
Endocrine 
Infections 
Obstetrics, gynaecology and the urinary tract 
culoskeletal and jo t di 
sep 1B 
Oct 1B 
Nov 1B 
Dec 1B 
Jan lg 
Feb lg 
Marig 
Apr lg 
May lg 
Jun lg 
Jul lg 
Aug lg 
sep lg 
Zoom 
Oct lg 
Nov lg 
Dec lg 
Jan 20 
Show medication from 
C) Last 6 months 
C) Last year 
• Last S years 
Close

The template links to a QRISK2 Calculator which populates based on the patient’s medical record:

QRISKS2 (2015) Calculator 
The product is intended to aid and supplement not substitute for, the expertise and judgement of physicians, 
pharmacists or other healthcare professional. All information is provided on the basis that the healthcare 
practitioners responsible for patient care will retain full and sole responsibility for deciding any treatment to 
prescribe or dispense for all patients and, in particular whether the use of information provided by the product 
is safe, appropriate, or effective for any particular patient or in any particular circumstance. 
Patient Data 
systolic ap 
Postcode 
Total / HDL cholesterol ratio 
Ethnicty 
• Male 
31 02 
NEI ISG 
o 
Female 
mmHg 
Kghmz 
White/Not Stated 
Medical History 
Smoking status Non smoker 
Diabetes category Not diabetic 
Family history of premature coronary heart disease 
Treated for hypertension 
Atrial fibrillation 
Z] Rheumatoid anhrtis 
Chronic renal disease 
Z] Personal history of CVD 
Patient has a history ot CVD making the calculation invalid. 
Cholesterol ratio not recorded, so will use calculated default of This will generate an estimated scor4 
Invalid Estimated 10yr QRlSK@2 Score: 3.02% 
Save to Record 
Statins 1 Selection Reasons

There is also a link to  Dr Chris Cates’ EBM Website to plot a Cate’s plot for shared decision making with the patient:

The template also helps the clinician to generate and send patient information leaflets:

A protocol can be run from the template to calculate Target Non-HDL Cholesterol:

The following patient status alerts help flag up to the clinician that a patient may need a review of their lipids or to conisder starting a statin:

‘DRM Due Lipids’ : This is the ‘Drugs Requiring Monitoring’ Resource which checks if the patient is due a lipids test if they are on certain medication eg antipsychotics.
2. Which searches/reports are available to help me assess and manage my Practice/CCG/PCN/Federation’s lipid health?

The following searches give an overview of lipid management/performance:

Location of searches (Clinical Reporting Unit): DCS > DCS Quality > Integrated Prevention

The searches are based on a ‘pyramid’ model (each level mutually exclusive):

  • Established CVD
  • Familial Hypercholesterolaemia (FH)
  • Primary prevention indicated e.g. qrisk >=10%, CKD
  • People who should be targeted for CVD risk assessment (often NHS health check but many of these patients are not eligible for a HC)

For each level you are given the size of the population – in the example above you can see that 6.2% of the pop have CVD, 0.5% have FH (excluding those with CVD), 19.1% are definitely eligible for primary prevention with lipid lowering, 2.3% of the population should be targeted for cvd risk assessment as their estimated risk based on the information in the record suggests their actual risk is >=10%.

For each level you are given the performance e.g. 60.4% of patients who are eligible for primary prevention are prescribed it.  70.3% are on lipid lowering or there is a good reason why not e.g. multiple adverse reactions to statins, has said they don’t want it in the last year.

For each level there are also searches to find the ‘missed’ patients. E.g. missed PAD coding, wrong stroke codes, missed CKD coding etc. 

The following search can find patients in your population who may have poor lipid-lowering medication concordance:

3. How can I find patients in my Practice/CCG/PCN/Federation who are likely to have undiagnosed Familial Hypercholesterolaemia (FH)?

The following searches are complex and identify patients who:

  • Might have undiagnosed FH
  • Have a genetic or clinical diagnosis of FH
  • Have had the Dutch Lipid Clinic Network Score (DLCNS) calculated (proxy for ‘have been fully assessed’), or those referred to lipid clinic.
Location of searches (Clinical Reporting Unit): DCS > DCS Quality > Lipids

The searches were created by working with lipid specialists to develop resources to compare all the FH detection tools: NICE, Simon Broome, DLCNS, and Famcat.  The searches were then refined to improve accuracy e.g. adding LDL and non-HDL criteria to the NICE criteria, adjusting for high triglycerides. Specialist Lipid Nurses then reviewed the patients identified and decided who needed further assessment and/or genetic testing.  This information was used to develop search strategies which can adjust sensitivity and specificity.  The chosen search strategy for the National FH Programme is:

  • Estimated DCLNS of 5 or more (adjusted for high triglyceride levels) OR
  • Patients with NICE Plus criteria for FH (adjusted for high triglyceride levels)  NICE PLUS includes LDL-C and NON-HDL-C as well as TC.
4. How can I find patients in my Practice/CCG/PCN/Federation who may benefit from PCSK9 Inhibitors?

The following searches can help identify patients who meet referral criteria for PCSK9i :

Location of searches (Clinical Reporting Unit): DCS > DCS Quality > Lipids

Video Demonstration

Please see below for a video demonstration of the resources in action on SystmOne:


Get in touch

If you have any questions regarding access, or the use of the CDRC Precision tools, please get in touch: contact-CDRC@ahsn-nenc.org.uk

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Lipids, Familial Hypercholesterolaemia (FH) and PCSK9i Guide for SystmOne

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