Correspondence to D Wonderling David.Wonderling@nice.org.uk What you need to know Offer 80 mg atorvastatin (unless contraindicated or previously not tolerated) as soon as possible to people with atherothrombotic cardiovascular disease (CVD) 2.0 mmol LDL-C (or 2.6 mmol/L non-HDL) is the most cost effective target for patients with established atherothrombotic CVD Consider ezetimibe for patients with atherothrombotic CVD, even if their cholesterol level is below the target While mortality from acute cardiovascular disease (CVD) has been falling in most developed countries, more people are now living with established CVD, including coronary heart disease, peripheral arterial disease, and stroke or transient ischaemic attack. Targets between 1.4 mmol/L and 1.8 mmol/L have been advocated by specialist societies and expert consensus, based on data from randomised controlled trials (RCTs).56 Achievement of these targets has been poor, and as of September 2023, in England, only about one third of people with CVD who had a cholesterol test in the last 12 months had either LDL-C below 1.8 mmol/L or non-HDL-C below 2.5 mmol/L.7 This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE), first published in 2014, and updated in December 2023, incorporating for the first time LDL-C targets for people with CVD.8 This guideline is the first to incorporate economic modelling and cost effectiveness in the calculation of cholesterol targets, which could mean that it is more easily implemented. Randomised controlled trials have shown consistently that reduction of LDL-C by prescribing statins reduces the risk of major cardiovascular events and cardiovascular mortality by approximately one fifth for each 1 mmol/L reduction in LDL-C.2 For people with established CVD, cost utility analysis in an NHS setting showed that high intensity statins are highly cost effective when compared with no treatment or any other statin regimen.9 Offer atorvastatin 80 mg to people with CVD, whatever their cholesterol level. To inform this new recommendation, a cost utility analysis was developed using estimates of the impact of lipid lowering treatments on LDL-C (from an original network meta-analysis of RCTs),10 combined with estimates of the impact of LDL-C reduction on major cardiovascular events (from a published meta-analysis of statin RCTs).2 The economic model measured the impact of lipid lowering treatments across a range of baseline LDL-C levels (0.3 to 4.0 mmol/L), on reduced admissions to hospital (stroke, myocardial infarction, and cardiovascular procedures), increases in life expectancy, and improvements in quality of life.