Cardiovascular
How NZ, Australian, and European guidelines differ on when to start treatment, what LDL-C target to set, and which medicines you can actually prescribe.
Where they agree
Where they diverge
Comparison
| Domain | NZ - BPAC / Heart Foundation NZ | AU - Heart Foundation AU / NPS | International - ESC/EAS 2019 |
|---|---|---|---|
| Treatment threshold (primary prevention) |
5-yr CVD risk ≥15% using PREDICT-CVD. Treat regardless of calculated risk if BP ≥180/110 mmHg or total cholesterol ≥8 mmol/L. | 5-yr CVD risk ≥10-15% - a lower threshold than NZ, partly reflecting PBS reimbursement structure. | Based on SCORE2 risk category. Initiate for "high" risk (10-yr SCORE2 ≥5-10%) or established atherosclerotic CVD. |
| LDL-C target High risk / primary prevention |
<2.0 mmol/L or ≥40% reduction from untreated baseline.↑ vs ESC | <2.0 mmol/L; non-HDL-C <2.5 mmol/L. Broadly aligned with NZ for primary prevention. | High risk: <1.8 mmol/L AND ≥50% reduction from baseline. Moderate risk: <2.6 mmol/L. |
| LDL-C target Very high risk / secondary prevention |
<1.8 mmol/L preferred for established CVD or very high risk. | <1.4 mmol/L for post-ACS or established high-risk atherosclerotic CVD (Heart Foundation AU 2023 update). | Very high risk: <1.4 mmol/L AND ≥50% reduction. Extreme risk (recurrent events on max therapy): <1.0 mmol/L. |
| Non-HDL-C target | <2.5 mmol/L (high risk); <2.2 mmol/L (secondary prevention). Useful when LDL is unreliable. | <2.5 mmol/L (high risk). Alternative target in hypertriglyceridaemia or when LDL-C is unreliable. | High risk: <2.2 mmol/L. Very high risk: <1.7 mmol/L. Extreme risk: <1.4 mmol/L. |
| First-line statin | Atorvastatin 40mg (high-intensity, fully funded). Simvastatin 40mg as moderate-intensity alternative.Funded | Atorvastatin 40-80mg or rosuvastatin 20-40mg. Both PBS-listed without restriction for eligible patients. | High-intensity statin to maximum tolerated dose. Atorvastatin 40-80mg or rosuvastatin 20-40mg preferred. |
| Add-on: ezetimibe | Funded with restriction: confirmed familial hypercholesterolaemia, or documented intolerance to at least two statins. Not funded simply for failure to reach LDL target.Restricted | PBS-listed; add to statin when LDL-C target not met. No special access criteria required. | Add ezetimibe if LDL target not met on maximum tolerated statin. Standard second step before considering PCSK9 inhibitors. |
| PCSK9 inhibitors | Evolocumab and alirocumab not funded in NZ. Private cost is substantial. Specialist referral is the appropriate pathway for very high-risk patients.Not funded | PBS-listed for: FH with LDL ≥5.0 mmol/L on max statin and ezetimibe; or secondary prevention with LDL ≥2.6 mmol/L on maximum tolerated therapy. | Recommended for very high and extreme risk not at target on statin and ezetimibe. Part of standard treatment algorithm, not a last resort. |
| Risk calculator | PREDICT-CVD. NZ-specific - incorporates ethnicity, NZDep deprivation index, and clinical history. Not cross-comparable with other calculators.1 | Australian CVD risk calculator (NVDPA framework). Separate tool; not interchangeable with PREDICT-CVD. | SCORE2 (age 40-69 years); SCORE2-OP for age 70 or older. Not validated in NZ or Australian populations. |
| Monitoring | Fasting lipid panel 6-8 weeks after initiation or dose change. Annually once stable. Baseline LFTs only if symptomatic; CK only if myalgia. | Fasting lipids 6-12 weeks post-initiation, then 12-monthly. CK only if myalgia symptoms present. | 8-12 weeks post-initiation or dose change, then 12-monthly once at target. |
NZ clinical context
PHARMAC funding and population-specific considerations
Verify current criteria at pharmac.govt.nz as they change. As at 2024:
PREDICT-CVD includes ethnicity as an input variable and is calibrated to NZ population data - it is the appropriate tool for NZ practice and should be used in preference to SCORE2 or the Australian calculator. When using other calculators, the Heart Foundation NZ recommends applying ethnicity-based risk multipliers to reflect higher CVD event rates in Maori and Pacific peoples at equivalent calculated risk scores.1
Consider FH if untreated LDL-C is ≥5.0 mmol/L, or ≥4.0 mmol/L in the presence of a family history of premature CVD or hypercholesterolaemia. Apply the Dutch Lipid Clinic Network (DLCN) criteria or Simon Broome criteria to estimate probability. Refer to a specialist for confirmation - this is the pathway to funded rosuvastatin and ezetimibe, and to consideration of PCSK9 inhibitors on a private or named patient basis.
Bottom line for NZ practice
What this means in the consulting room
Sources