When should my GP refer me to an FH clinic? 

In the UK, a GP should refer you to a specialist familial hypercholesterolaemia (FH) clinic if your blood tests show exceptionally high cholesterol or if your family history suggests a genetic condition. Specifically, a referral is triggered if an adult has a total cholesterol level above 7.5 mmol/L or an LDL level above 4.9 mmol/L, especially alongside a history of early heart disease. Specialist clinics are essential for confirming a genetic diagnosis and providing access to advanced treatments that go beyond standard primary care. 

What We’ll Discuss in This Article 

• The specific cholesterol thresholds that trigger a specialist referral. 

• Why age and family history are critical factors in the referral process. 

• The role of physical signs like tendon xanthomas and corneal arcus. 

• When cascade testing for family members becomes a clinical priority. 

• Specialist care for children and during pregnancy planning. 

• What happens if standard statin therapy does not meet target levels. 

• Using the BMI Calculator to support overall cardiovascular health. 

Primary Referral Thresholds for Adults 

The most common reason for a referral to a specialist lipid clinic is a significantly elevated cholesterol reading 

Under current NICE (National Institute for Health and Care Excellence) guidance, your GP should consider a referral if you meet the following lipid criteria: 

• Total Cholesterol: Above 7.5 mmol/L. 

• LDL Cholesterol: Above 4.9 mmol/L. 

• Exceptional Levels: Any adult with a total cholesterol above 9.0 mmol/L should be referred even without a family history of heart disease. 

Family History and Early Heart Disease 

If you have high cholesterol and a family history of premature coronary heart disease (CHD), the suspicion of FH increases. In clinical terms, ‘premature’ refers to a heart attack, stroke, or the need for a bypass in: 

• A first-degree relative (parent or sibling) before the age of 60. 

• A second-degree relative (grandparent, aunt, or uncle) before the age of 50. 

If your lipid levels are high and you have this family background, your GP will use the Simon Broome or Dutch Lipid Clinic Network (DLCN) score. If you score high enough, a referral to a specialist clinic for DNA analysis is mandatory under UK clinical protocols. 

Physical Signs as Referral Triggers 

During a routine check, a GP may notice physical changes that suggest your body is struggling to process excess cholesterol. If these signs are present, a referral is usually made regardless of your current age. 

Physical Sign	Description	Clinical Urgency
Tendon Xanthomas	Swelling or lumps on the knuckles or Achilles tendon.	High (Definite indicator of FH).
Corneal Arcus	A white/grey ring around the iris in those under 45.	High (Suggests long-term high cholesterol).
Xanthelasmas	Yellow fatty deposits around the eyelids.	Moderate (Needs lipid profile check).

Specialist Care for Children 

If a parent is diagnosed with FH, their children should be referred to a specialist paediatric lipid clinic. Unlike adults, children are seen in a child-focused setting by specialists who understand the unique needs of growing bodies. 

NICE  guidelines recommend that children at risk should be referred for a DNA test by the age of 10. If the family mutation is unknown, the referral is based on a total cholesterol level above 6.7 mmol/L or an LDL level above 4.0 mmol/L. This ensures that lifestyle advice and monitoring can begin early, preventing the silent buildup of plaque in the arteries. 

Treatment Optimization and Intolerance 

Even if you do not have a genetic condition, your GP may refer you to a specialist clinic if your cholesterol is difficult to manage. This is often known as ‘treatment optimisation’. 

You should be referred if: 

• You have tried the maximum dose of high-intensity statins plus ezetimibe but your LDL has not dropped by at least 50%. 

• You are intolerant to multiple types of statins and require access to advanced injectable therapies like PCSK9 inhibitors or Inclisiran. 

• You are planning a pregnancy, as most lipid-lowering medications must be stopped and managed by a specialist during this time. 

To Summarise 

Your GP should refer you to an FH clinic if your total cholesterol is above 7.5 mmol/L (or 9.0 mmol/L without a family history), if you show physical signs like tendon xanthomas, or if you have a family history of early heart disease. Specialist clinics are also the primary route for genetic testing, paediatric care, and advanced injectable treatments. Early referral is essential to provide a definite diagnosis and prevent the long-term risks of untreated high cholesterol. 

If you experience sudden, crushing chest pain, difficulty breathing, or sudden weakness on one side of your body, call 999 immediately. 

You may find our free BMI Calculator helpful for monitoring your overall health, as weight management is a key supportive factor in any cardiovascular care plan. 

Authority Snapshot 

Dr. Rebecca Fernandez is a UK-trained physician with an MBBS and experience in general surgery, cardiology, internal medicine, and emergency care. She has managed critically ill patients, stabilised acute trauma cases, and provided comprehensive care across inpatient and outpatient settings. This guide is based on 2026 clinical standards from the NHS and NICE regarding the identification and specialist referral of familial hypercholesterolaemia.