Cardiovascular Health
A clinical reference for UK primary care
Last reviewed 3 May 2026 · Next review July 2026
Cardiovascular disease is the UK's biggest single cause of premature death and a major driver of health inequalities. Around 7.6 million people across the UK live with a heart or circulatory disease.1
CVD prevention is built around two NICE guidelines that primary care delivers most: NG238 for risk assessment and lipid modification, and NG136 for hypertension. NG238 specifies QRISK3 as the current risk tool, with a 10-year score of 10% or more as the threshold to offer a statin, and shared decisions for those below the threshold.2,3
Most cardiovascular risk management happens in primary care. Specialist input is reserved for established disease, suspected secondary causes, or where risk factors are difficult to control.2,3
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Hypertension diagnostic thresholds
Diagnosis requires both an elevated clinic measurement and confirmation by ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM). Per NG136.3
Stage 1 hypertension
Clinic ≥140/90 · ABPM/HBPM ≥135/85 mmHg
In adults under 80, NG136 recommends discussing antihypertensive treatment if target organ damage, established CVD, renal disease, diabetes, or 10-year CVD risk ≥10%.
3Stage 2 hypertension
Clinic ≥160/100 · ABPM/HBPM ≥150/95 mmHg
NG136 recommends offering antihypertensive treatment to adults of any age.
3Stage 3 / Severe hypertension
Clinic ≥180/120 mmHg
Same-day specialist review if signs of retinal haemorrhage, papilloedema, life-threatening symptoms, or suspected phaeochromocytoma.
3BP target — 80 and over
Clinic <150/90 · ABPM/HBPM <145/85 mmHg
Use clinical judgement in frailty or multimorbidity.
3CONFIRMING THE DIAGNOSIS
A single clinic reading is not sufficient. Confirm with ABPM (or HBPM if ABPM unsuitable). HBPM thresholds are 5 mmHg lower than clinic measurements. Investigate for target organ damage and assess CV risk while awaiting confirmation.3
Identifying those at risk
PRIMARY PREVENTION
QRISK3 ≥10%
NG238 recommends offering a high-intensity statin for primary prevention of CVD where 10-year QRISK3 score is 10% or more. For QRISK3 below 10%, do not rule out treatment if there is informed preference or risk may be underestimated.2
RISK TOOLS
QRISK3 (ages 25 to 84)
QRISK3 incorporates risk factors not in QRISK2: severe mental illness, corticosteroid use, atypical antipsychotics, SLE, migraine, erectile dysfunction. Some clinical systems still use QRISK2; the 10% threshold applies to either.2,4
WHERE QRISK3 IS NOT APPROPRIATE
High-risk groups
Do not use QRISK3 for adults with type 1 diabetes, eGFR <60 mL/min/1.73m² with or without albuminuria, or familial hypercholesterolaemia. These are treated as high-risk by default.2
LIPID RESPONSE TARGETS
Non-HDL ≥40% reduction
NG238 specifies a 40% reduction in non-HDL cholesterol from baseline at 2 to 3 months on a high-intensity statin as the response target.2
CVD risk assessment in primary care
The five-step pathway that primary care delivers under NG238.2
Identify
Adults aged 25 to 84 not already known to be at high risk
Measure
Lipids, BP, HbA1c, smoking status, family history
Calculate
10-year CVD risk using QRISK3
Discuss
Shared decision around lifestyle and statin treatment
Initiate
High-intensity statin if QRISK3 ≥10% and patient agrees
Review
Lipid response at 2 to 3 months; aim for ≥40% non-HDL reduction
Referral pathways
Clinic BP ≥180/120 mmHg with retinal haemorrhage or papilloedema, life-threatening symptoms, or suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor, abdominal pain, diaphoresis).3
Suspected heart failure (NG106): NT-proBNP >2,000 ng/L — 2-week referral; 400–2,000 ng/L — 6-week referral. Suspected angina or ACS, suspected arrhythmia requiring assessment, abnormal ECG, or established CVD with poorly controlled risk factors.5
Suspected familial hypercholesterolaemia (per CG71). Adults with statin intolerance after trying alternatives. Consideration of specialist lipid-lowering therapy beyond statins.6
Resistant hypertension (uncontrolled despite optimal doses of three agents including a diuretic). Suspected secondary causes including primary aldosteronism, renovascular disease, or rare causes.3
Suspected TIA: same-day assessment per NG128. Established stroke or TIA: secondary prevention pathway including antiplatelet, statin and BP optimisation.7
Find all NICE updates relevant to primary care
View NICE GuidelinesThis disease hub is intended for UK Healthcare Professionals only. Content reports established clinical knowledge and current NICE guidance. It is not a substitute for clinical judgment or for the original guidelines. Last reviewed 28 April 2026.
References
All sources verified at last review. Where primary literature is cited, original peer-reviewed publications are linked.
- 1.British Heart Foundation. UK Cardiovascular Disease Statistics Factsheet. Latest edition.
- 2.National Institute for Health and Care Excellence. Cardiovascular disease: risk assessment and reduction, including lipid modification. NICE guideline NG238. Published May 2023.
- 3.National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management. NICE guideline NG136. Published August 2019, updated November 2023.
- 4.Hippisley-Cox J, Coupland C, Brindle P. Development and validation of QRISK3 risk prediction algorithms to estimate future risk of cardiovascular disease: prospective cohort study. BMJ. 2017;357:j2099.
- 5.National Institute for Health and Care Excellence. Chronic heart failure in adults: diagnosis and management. NICE guideline NG106.
- 6.National Institute for Health and Care Excellence. Familial hypercholesterolaemia: identification and management. NICE guideline CG71.
- 7.National Institute for Health and Care Excellence. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. NICE guideline NG128.