MRCGP AKT · Cardiorenal-Metabolic

The CVD Modern Service Framework (July 2026) and cardiovascular-kidney-metabolic prevention

What England’s first Modern Service Framework asks of general practice — finding the ‘missing millions’ and treating to target — with the NICE blood-pressure and lipid thresholds you need for the AKT.

Reviewed and kept current

Last editorial review: 28 September 2026 · Next scheduled refresh: March 2027.

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Clinical vignette

Begin with the patient. Read the case, weigh the options, then work through the unit.

A 56-year-old woman of Black African family origin attends an NHS Health Check. She has no cardiovascular disease, diabetes or kidney disease, and does not smoke. Her clinic blood pressure is 152/94 mmHg on two readings; her home readings over a week average 141/89 mmHg. Non-HDL cholesterol is 4.9 mmol/L, and her 10-year QRISK3 score is 14%. HbA1c and urine ACR are normal.

She works two jobs and cannot easily take time off for appointments. She asks whether she really needs “pills for life”.

Options to weigh

  • Stage 1 hypertension: discuss starting drug treatment, with lifestyle advice, in people under 80 with a 10-year cardiovascular risk of 10% or more (NICE NG136).
  • Step 1: a calcium-channel blocker if aged 55 or over, or of Black African or African–Caribbean family origin, without type 2 diabetes (NICE NG136).
  • Offer atorvastatin 20 mg if the 10-year QRISK3 score is 10% or more, after discussing risk; aim for a reduction in non-HDL cholesterol of more than 40% (NICE NG238).
  • If, after a discussion in absolute numbers, she judges that the benefits do not outweigh the harms and burdens, respect the decision, offer lifestyle support, record the discussion and revisit it later (NICE NG197).
Were you aware?

The CVD Modern Service Framework (July 2026) names “finding the missing millions” as its first theme: active case-finding of blood pressure, cholesterol and the other cardiovascular-kidney-metabolic risk factors. Practices should expect searches for undiagnosed hypertension and for people above the QRISK3 threshold who have not been offered a statin.

The Golden Triangle

Every condition has a Golden Triangle: what we know, what the evidence says, and what actually happens. Each apex is rated Red, Amber or Green. The Equinox, at the centre, is where all three meet in equal measure; the arrow shows the apex that must be drawn in to reach it.

Golden Triangle: Cardiovascular disease preventionGolden Triangle for Cardiovascular disease prevention (UK (NHS England)). Knowledge: Green; Evidence: Green; Real-world: Red. The triangle is white because it has not reached the Equinox. Real-world has two arrows toward the Equinox.Knowledge · GreenEvidenceGreenReal-worldRed

Cardiovascular disease prevention UK (NHS England)

ApexRatingWhy
KnowledgeGreenQRISK3 gives a 10-year CVD risk; the MSF names seven linked CVKM risk factors to find and treat together.
EvidenceGreenNICE offers atorvastatin 20 mg at QRISK3 ≥10% after discussing risk; aim for a >40% fall in non-HDL cholesterol.
Real-worldRed56.7% of people at risk take lipid-lowering therapy (Mar 2025). Under-75 CVD deaths are 2.2 times higher in the most v least deprived areas.

Pull toward the Equinox — Real-world. Search for people above the QRISK3 threshold not offered a statin; use clinical judgement where QRISK3 underestimates risk; give risk as absolute numbers out of 100.

Sources for this triangle
  1. NICE NG238. Cardiovascular disease: risk assessment and reduction, including lipid modification. (December 2023)
  2. Department of Health and Social Care and NHS England. Cardiovascular disease modern service framework. (7 July 2026)
  3. NICE NG197. Shared decision making. (Published 17 June 2021)
  4. CVDPREVENT. Fifth Annual Audit Report, audit period to March 2025 (HQIP). (2025 report (published 2026))
  5. Office for Health Improvement and Disparities. Fingertips indicator 40401: under-75 mortality rate from cardiovascular diseases. (2025 data release (accessed 7 October 2026))
Golden Triangle: HypertensionGolden Triangle for Hypertension (UK (NHS England)). Knowledge: Green; Evidence: Green; Real-world: Red. The triangle is white because it has not reached the Equinox. Real-world has two arrows toward the Equinox.Knowledge · GreenEvidenceGreenReal-worldRed

Hypertension UK (NHS England)

ApexRatingWhy
KnowledgeGreenClinic ≥140/90 mmHg, confirmed by an ABPM or HBPM average ≥135/85 mmHg; stage 1, stage 2 and severe are defined.
EvidenceGreenStepwise A, C and D drug treatment; clinic targets below 140/90 under 80 and below 150/90 at 80 or over (NG136).
Real-worldRedNearly 3 million people with hypertension are not treated to target (Mar 2025). Among them, CVD deaths are higher in the most deprived areas.

Pull toward the Equinox — Real-world. Case-find at NHS Health Checks and opportunistic contacts; confirm with ABPM or HBPM; search for undiagnosed hypertension; treat to NG136 targets.

Sources for this triangle
  1. NICE NG136. Hypertension in adults: diagnosis and management. (Published 28 August 2019; last updated 26 February 2026)
  2. Department of Health and Social Care and NHS England. Cardiovascular disease modern service framework. (7 July 2026)
  3. CVDPREVENT. Fifth Annual Audit Report, audit period to March 2025 (HQIP). (2025 report (published 2026))
  4. CVDPREVENT data explorer and API (NHS Benchmarking Network / OHID). (Indicators to March 2026 (accessed 7 October 2026))
Golden Triangle: Dyslipidaemia (raised cholesterol)Golden Triangle for Dyslipidaemia (raised cholesterol) (UK (NHS England)). Knowledge: Green; Evidence: Green; Real-world: Red. The triangle is white because it has not reached the Equinox. Real-world has two arrows toward the Equinox.Knowledge · GreenEvidenceGreenReal-worldRed

Dyslipidaemia (raised cholesterol) UK (NHS England)

ApexRatingWhy
KnowledgeGreenNon-HDL and LDL cholesterol are measured; suspect FH if total cholesterol >7.5 mmol/L with premature CHD in the family.
EvidenceGreenAtorvastatin 20 mg at QRISK3 ≥10%; 80 mg in established CVD to LDL-C ≤2.0 mmol/L, then ezetimibe (NICE NG238).
Real-worldRedIn CVD, 48.3% have cholesterol at target: 37.5% of Black v 48.5% of White patients (Mar 2025). Women reach target less often than men.

Pull toward the Equinox — Real-world. Search for people above QRISK3 10% not offered a statin and secondary-prevention patients off target; check adherence; add ezetimibe; use a decision aid in absolute numbers.

Sources for this triangle
  1. NICE NG238. Cardiovascular disease: risk assessment and reduction, including lipid modification. (December 2023)
  2. Department of Health and Social Care and NHS England. Cardiovascular disease modern service framework. (7 July 2026)
  3. NICE NG197. Shared decision making. (Published 17 June 2021)
  4. CVDPREVENT. Fifth Annual Audit Report, audit period to March 2025 (HQIP). (2025 report (published 2026))
  5. CVDPREVENT. Deep dive: inequalities in cholesterol management by sex for patients with CVD (HQIP). (2024)

Reflect

Given the gap, what is your duty as the doctor — and how would you inform the patient of their access to care?

Unit overview

What this unit covers

Pocket-sized and self-contained: three AKT-style questions, the answers explained, an expanded discussion with hyperlinked guidance, a decision algorithm and a certificate.

Unit code
MDA-AKT-CK-CVH-02
AKT domain
Clinical knowledge≈80% (128 of 160 items)
Study time
25 minutesCPD, self-certified
Pass mark
2 of 3unlocks your certificate
RCGP Topic Guide: Cardiovascular healthRCGP Topic Guide: Population and planetary healthRCGP Topic Guide: Metabolic problems and endocrinologyRCGP · Applied Knowledge Test

By the end of this unit you will be able to

✓State the headline ambition and four themes of the CVD Modern Service Framework (DHSC/NHS England, 7 July 2026).
✓List the seven cardiovascular-kidney-metabolic (CVKM) risk factors the framework manages together.
✓Apply NICE NG136 blood-pressure targets and NG238 lipid-lowering thresholds and targets.
✓Contrast NICE lipid targets with ESC targets.
The unit

Five steps, in order

Answer first, then learn. Each section unlocks as you progress, and your progress is saved in this browser.

1Three single best answer questions

Commit to an answer for all three single best answer questions, then submit. Sections 2–4 open on submission; your certificate opens at 2/3 or better.

Question 1 of 3

The Cardiovascular Disease Modern Service Framework was published by the Department of Health and Social Care and NHS England in July 2026.

What is its headline ambition?

Question 2 of 3

A 61-year-old man had a myocardial infarction a year ago. He takes atorvastatin 80 mg daily with good adherence and no side-effects. His LDL cholesterol is 2.6 mmol/L (non-HDL 3.3 mmol/L).

What is the most appropriate next step according to NICE?

Question 3 of 3

A 68-year-old woman has primary hypertension. She has no cardiovascular disease, diabetes or CKD.

What clinic blood-pressure target does NICE recommend for her?

2Answers explained

Question 1

Correct answer B. To reduce premature (under 75) mortality from heart disease and stroke by 25% within 10 years

The framework’s ambition is to reduce premature (under 75) mortality from heart disease and stroke by 25% within 10 years. It is the first of the Modern Service Frameworks committed to in the 10 Year Health Plan.

Option E echoes the earlier (2019) NHS Long Term Plan / PHE detection ambitions — a plausible distractor from a previous policy.

Question 2

Correct answer E. Add ezetimibe

NICE NG238 (2023) sets a secondary-prevention target of LDL-C ≤2.0 mmol/L or non-HDL-C ≤2.6 mmol/L. If this is not reached on the maximum tolerated high-intensity statin, add ezetimibe. Further options (inclisiran, PCSK9 inhibitors, bempedoic acid) follow NICE technology appraisal criteria.

The “>40% reduction in non-HDL” goal applies to primary prevention. Fibrates and omega-3 supplements are not recommended for CVD prevention.

Question 3

Correct answer C. Below 140/90 mmHg

NICE NG136: clinic BP target below 140/90 mmHg for adults under 80; below 150/90 for adults aged 80 or over. Home or ambulatory targets are 5 mmHg lower (below 135/85 and below 145/85).

Below 130/80 applies in CKD with ACR ≥70 mg/mmol (NG203). The ESC recommends lower targets (systolic 120–129 if tolerated) — a UK vs ESC difference.

3Expanded discussion, worked examples & guidance

1. The CVD Modern Service Framework in one page

  • Published 7 July 2026 by DHSC and NHS England; the first Modern Service Framework under the 10 Year Health Plan.
  • Ambition: 25% reduction in premature (under 75) deaths from heart disease and stroke within 10 years.
  • Approach: cardiovascular-kidney-metabolic (CVKM) — seven linked risk factors assessed together rather than in separate pathways, the ‘ABCDE’ risks: atrial fibrillation, albuminuria, blood pressure, cholesterol, diabetes (including pre-diabetes), excess weight and kidney function (eGFR) (priority 2). Stopping smoking is a separate priority (priority 1).
  • Structure: 12 priorities for the first three years, grouped under four themes, each with a baseline, 3-year target, 10-year ambition and variation metric, with ICBs and local government accountable:
    1. Finding the missing millions — tobacco-dependence treatment; active case-finding of CVKM risk factors (BP, AF, cholesterol, glucose, weight, kidney function including ACR); inherited lipid conditions.
    2. Driving treatment to target — hypertension and cholesterol treated to target, including in established CVD; diabetes care processes; SGLT2-inhibitor uptake; rapid implementation of the four pillars in HFrEF.
    3. Ensuring timely, equitable, high-quality acute care — stroke and heart-attack pathways.
    4. Living with CVD and expanding access to rehabilitation — expanded access, including digital and hybrid models.
  • Delivery is linked to 2026/27 QOF and to national tariffs; a Diabetes UK prevention partnership was launched alongside it.
What it means for a practiceExpect searches for undiagnosed hypertension and AF, un-coded CKD (ACR missing), people above the QRISK3 threshold not offered a statin, secondary-prevention patients not at lipid target, and HFrEF patients not on all four pillars. The Statistics units on audit and prescribing data (Unit 11) apply directly.

2. Hypertension (NICE NG136)

ClinicABPM / HBPM average
Stage 1140/90 – 159/99135/85 – 149/94
Stage 2160/100 – 179/119≥150/95
SevereSystolic ≥180 or diastolic ≥120—
Target, age <80<140/90<135/85
Target, age ≥80<150/90<145/85

Treat stage 1 in people under 80 with target-organ damage, established CVD, renal disease, diabetes, or a 10-year CVD risk of 10% or more; consider in people under 60 with lower risk. Treat all stage 2.

Drug steps: Step 1 — ACEi/ARB if type 2 diabetes (any age or ethnicity) or age under 55 and not of Black African or African–Caribbean family origin; CCB if 55 or over, or of Black African or African–Caribbean family origin (without T2D). Step 2 — add CCB or thiazide-like diuretic to ACEi/ARB, or add ACEi/ARB or thiazide-like diuretic to CCB (ARB preferred to ACEi in Black African or African–Caribbean people). Step 3 — A + C + D. Step 4 — check adherence and confirm with ABPM; consider spironolactone if K⁺ ≤4.5 mmol/L, or an alpha- or beta-blocker if K⁺ >4.5, and seek specialist advice.

3. Lipids (NICE NG238)

  • Primary prevention: offer atorvastatin 20 mg if 10-year QRISK3 is 10% or more (after discussing risk; do not rule out treatment below 10% if the patient prefers it). Also offer it in CKD, and in type 1 diabetes where criteria are met. Aim for a >40% reduction in non-HDL-C.
  • Secondary prevention: atorvastatin 80 mg (lower dose if interactions, CKD or side-effects). Target LDL-C ≤2.0 mmol/L or non-HDL-C ≤2.6 mmol/L; add ezetimibe if not achieved, then consider inclisiran or a PCSK9 inhibitor per technology appraisals.
  • Suspect familial hypercholesterolaemia if total cholesterol >7.5 mmol/L with a family history of premature CHD; use the Simon Broome or Dutch Lipid Clinic criteria.
  • QRISK3 underestimates risk in people with severe mental illness, on antipsychotics, or with HIV and some other conditions — use clinical judgement.
UK vs ESCESC dyslipidaemia guidance uses risk-category LDL-C targets (e.g. <1.4 mmol/L and ≥50% reduction for very-high-risk patients) and SCORE2/SCORE2-OP. NICE uses QRISK3 and the targets above. The AKT expects NICE.

4. Worked example — applying the numbers

Primary-prevention statin effect

A 56-year-old woman with QRISK3 14% starts atorvastatin 20 mg. Baseline non-HDL-C is 5.0 mmol/L; three months later it is 3.2 mmol/L.

  1. Reduction = (5.0 − 3.2)/5.0 = 36%.
  2. Below the 40% goal → check adherence, then consider increasing the dose.

Answer. 36% reduction — review adherence and titrate.

High-yield AKT facts
  • Confirm hypertension with ABPM or HBPM before diagnosis (unless severe).
  • Same-day referral: BP ≥180/120 with signs such as papilloedema or retinal haemorrhage, or life-threatening symptoms.
  • Statin side-effects: stop, and re-challenge or switch; check CK if muscle symptoms; ALT at baseline, 3 months and 12 months.

References and further reading

Guidance checked at the last editorial review (28 September 2026). Always use the current version.

  1. DHSC/NHS England — Cardiovascular disease modern service framework (July 2026)
  2. NHS England — Cardiovascular disease
  3. NICE NG136 — Hypertension in adults: diagnosis and management
  4. NICE NG238 — Cardiovascular disease: risk assessment and reduction, including lipid modification
  5. NICE NG197 — Shared decision making
  6. NICE NG196 — Atrial fibrillation: diagnosis and management
  7. QRISK3 calculator
  8. BHF — What England’s CVD framework could mean for patients
4Decision algorithm

CVKM case-finding and treatment to target

1

Start

Adult aged 40–74 (NHS Health Check) or opportunistic contact; everyone with a CVKM risk factor.

2

Action

Check BP, pulse rhythm (AF), lipids, HbA1c, BMI, smoking status, eGFR and urine ACR; calculate QRISK3.

3

Decision

Clinic BP ≥ 140/90?

YesConfirm with ABPM/HBPM → treat by NG136 stage and risk; target < 140/90 (< 150/90 if ≥ 80).
NoRecheck at least every 5 years (sooner if near threshold).
4

Decision

Established CVD?

YesAtorvastatin 80 mg → target LDL-C ≤ 2.0 or non-HDL ≤ 2.6 mmol/L → add ezetimibe → consider inclisiran/PCSK9i.
NoQRISK3 ≥ 10% (or CKD/T1DM criteria) → offer atorvastatin 20 mg; aim for a > 40% fall in non-HDL-C.
5

Action

Treat AF (anticoagulate by CHA₂DS₂-VASc), CKD (ACEi/ARB, SGLT2i), non-diabetic hyperglycaemia (NHS Diabetes Prevention Programme), obesity and smoking.

6

Outcome

Record, recall and audit against the framework’s priorities; offer cardiac rehabilitation after events.

Revision summary; apply clinical judgement and local pathways.

5Certificate of completion

You have met the pass mark. Enter your details to issue your personalised certificate of completion, then save it as a PDF for your appraisal or revalidation portfolio.

Where next?

← CKD in cardiovascular disease: ‘STAMP on CKD’ (ESC/ERA 2026) and NICE NG203All MRCGP AKT topics →🎓 DCRM Certificate of Advanced Studies✉️ enquiry@mdacumen.com
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