LDL-C target levels (mg/dL) 2 RF:

LDL-C target levels (mg/dL)2 RF: <130CHD: 100

% not at LDL-C targets

2 RF CHD

Risk profile

63

8282.5

54.6

0

20

40

60

80

100 NHANES IIIL-TAP

Adult Population Not Reaching LDL-C Targets

ATP III: New Features of Guidelines—Focus on Multiple Risk Factors

• Persons with diabetes without CHD raised to level of CHD risk equivalent

• Framingham 10-year absolute CHD risk projections used to identify certain patients with 2 risk factors for more intensive treatment

• Persons with multiple metabolic risk factors (the metabolic syndrome) identified as candidates for intensified therapeutic lifestyle changes (TLC)

ATP III: New Features of Guidelines—Updated Lipid/Lipoprotein Classifications• Optimal LDL-C level: identified as <100 mg/dL• Categorical low HDL-C: raised to <40 mg/dL to more

accurately define patients at increased risk• TG classification cutpoints: lowered to focus more

attention on moderate elevations– normal: <150 mg/dL

– borderline high: 150–199 mg/dL

– high: 200–499 mg/dL

– very high: 500 mg/dL

Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

ATP III: New Features of Guidelines—Applying the Recommendations

• Complete fasting lipoprotein profile (TC, LDL-C, HDL-C, TG) recommended as preferred initial test

• Use of plant stanols/sterols and viscous fiber encouraged as therapeutic dietary options to enhance LDL-C lowering

• Strategies presented to improve adherence to therapeutic lifestyle changes (TLC), drug therapies

• Intensive TLC recommended for persons with the metabolic syndrome

• Non–HDL-C (TC minus HDL-C) goal recommended as secondary target for persons with high TG levels (200 mg/dL)


ATP III: LDL-C, HDL-C, TC Classification


High240Borderline high200–239Desirable<200

TC (mg/dL)High60Low<40

HDL-C (mg/dL)Very high190High160–189Borderline high130–159Above, near optimal100–129Optimal<100

LDL-C (mg/dL)

ATP III: Major CHD Risk FactorsOther Than LDL-C

• Cigarette smoking• Hypertension: BP 140/90 mm Hg or on antihypertensive

medication• Low HDL-C: 40 mg/dL*• Family history of premature CHD (1st-degree relative):

– male relative age 55 years– female relative age 65 years

• Age– male 45 years– female 55 years

*HDL-C 60 mg/dL is a negative risk factorand negates one other risk factor.

ATP III: Additional CHD Risk Factors

• Life-habit risk factors: targets for intervention; not used to set lower LDL-C goal

– obesity– physical inactivity– atherogenic dietEmerging risk factors: can help guide intensity of risk-reduction therapy; do not categorically alter LDL-C goals

– lipoprotein(a) – homocysteine– impaired fasting glucose – prothrombotic and – subclinical atherosclerotic proinflammatory

factors disease

ATP III: Assessment of Risk

For persons without known CHD, other forms of atherosclerotic disease, or diabetes:

• Count the number of risk factors.

• Use Framingham scoring for persons with 2 risk factors* to determine the absolute 10-year CHD risk.

*For persons with 0–1 risk factor, Framingham calculations are not necessary.


ATP III: Risk Categories, LDL-C Goals

<1600–1 risk factor*

<1302 risk factors (10-year risk 20%)

<100CHD and CHD risk equivalents (10-year risk >20%)

LDL-C Goal (mg/dL)Risk Category

*Almost all people with 0–1 risk factor have a 10-year risk <10%;thus, Framingham risk calculations are not necessary.


ATP III: LDL-C Treatment Cutpoints for Therapy

*Therapeutic lifestyle changes†Some authorities use LDL-C–lowering drugs if TLC does not achieve LDL-C <100 mg/dL; others use drugs to modify HDL-C and TG.

190 mg/dL(160–189 mg/dL: LDL-C–lowering

drug optional)

160 mg/dL0–1 risk factor

10-year risk 10%–20%: 130 mg/dL10-year risk 10%: 160 mg/dL

130 mg/dL2 risk factors

130 mg/dL(100–129 mg/dL: drug optional)†

100 mg/dLCHD and CHD risk equivalents

Consider Drug TherapyInitiate TLC*Risk Category

ATP III: Nutritional Components of the TLC Diet

*Trans fatty acids also raise LDL-C and should be kept at a low intake.Note: Regarding total calories, balance energy intake and expenditure tomaintain desirable body weight.

<200 mg/dCholesterol

~15% of total caloriesProtein

20–30 g/dFiber

50%–60% of total caloriesCarbohydrate(esp.complex carbs)

25%–35% of total caloriesTotal fat

Up to 20% of total caloriesMonounsaturated fat

Up to 10% of total caloriesPolyunsaturated fat

<7% of total caloriesSaturated fat*

Recommended IntakeNutrient

ATP III: Management of Very High LDL-C

• LDL-C 190 mg/dL usually traced to genetic formsof hypercholesterolemia

• Recommended actions:– early detection in young adults through cholesterol

screening to prevent premature CHD– family cholesterol testing to identify affected relatives– combination drug therapy usually required to achieve

target LDL-C levels


ATP III: Management of Low HDL-C • Low HDL-C: <40 mg/dL (no specific goal defined for

raising HDL-C)

• Targets of therapy:

– all persons with low HDL-C: achieve LDL-C goal; then weight, physical activity (if metabolic syndrome is present)

– those with TG 200–499 mg/dL: achieve non–HDL-C goal* as secondary priority

– those with TG <200 mg/dL: consider drugs for raising HDL-C (fibrates, nicotinic acid)

*Non–HDL-C goal is set at 30 mg/dL higher than LDL-C goal.

ATP III: Management of Elevated TG

Very low-fat diet, weight, physical activity, nicotinic acid or

fibrate

500Very high†

weight, physical activity, consider drug treatment to reach non–HDL-C goal‡

200–499High*

weight, physical activity150–199Borderline high*

Treatment StrategyTG Level (mg/dL)Classification

ATP III: The Metabolic Syndrome*

<40 mg/dL<50 mg/dL

MenWomen

>102 cm (>40 in)>88 cm (>35 in)

MenWomen

110 mg/dLFasting glucose130/85 mm HgBlood pressure

HDL-C150 mg/dLTG

Abdominal obesity† (Waist circumference‡)

Defining LevelRisk Factor

ATP III: Management of Diabetic

Dyslipidemia

• Primary target of therapy: identification of LDL-C; goal for persons with diabetes: <100 mg/dL

• Therapeutic options:

– LDL-C 100–129 mg/dL: increase intensity of TLC; add drug to modify atherogenic dyslipidemia (fibrate or nicotinic acid); intensify risk factor control

– LDL-C 130 mg/dL: simultaneously initiate TLC and LDL-C–lowering drugs

• TG 200 mg/dL: non–HDL-C* becomes secondary target

ATP III: LDL-C Measurements in Patients Hospitalized for Major Coronary Events

• Measure LDL-C on admission or within 24 hours

• General recommendations at discharge:

– LDL-C 130 mg/dL: discharge on drug therapy

– LDL-C 100–129 mg/dL: use clinical judgment*

• Advantages of initiating drug therapy at discharge:

– motivates patients to begin/continue risk-lowering therapy

– emphasizes consistency and continuous follow-up; no “treatment gap”

– may reduce early clinical events

Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA.

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

Assessing CHD Risk in MenStep 1: Age

YearsPoints

20-34 -935-39 -440-44 045-49 350-54 655-59 860-64 1065-69 1170-74 1275-79 13

Step 2: Total Cholesterol

TC Points at Points at Points at Points atPoints at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69

Age 70-79 <160 0 0 0 0

0160-199 4 3 2 1

0200-239 7 5 3 1

0240-279 9 6 4 2

1280 11 8 5 3

1

HDL-C(mg/dL) Points

60 -1

50-59 0

40-49 1

<40 2

Step 3: HDL-Cholesterol

Systolic BP PointsPoints

(mm Hg) if Untreated if Treated

<120 0 0120-129 0 1130-139 1 2140-159 1 2160 2 3

Step 4: Systolic Blood Pressure

Step 5: Smoking Status

Points at Points at Points at Points atPoints at

Age 20-39 Age 40-49 Age 50-59 Age 60-69Age 70-79

Nonsmoker 0 0 0 00

Smoker 8 5 3 11

Age

Total cholesterol

HDL-cholesterol

Systolic blood pressure

Smoking status

Point total

Step 6: Adding Up the Points

Point Total 10-Year Risk Point Total 10-Year Risk

<0 <1% 118%

0 1% 1210%

1 1% 1312%

2 1% 1416%

3 1% 1520%

4 1% 1625%

5 2% 1730%

6 2%7 3%8 4%9 5%

10 6%

Step 7: CHD Risk

ATP III Framingham Risk Scoring

© 2001, Professional Postgraduate Services®

www.lipidhealth.org


<9 <1% 2011%

9 1% 2114%

10 1% 2217%

11 1% 2322%

12 1% 2427%

13 2% 25 30%

14 2%15 3%16 4%17 5%18 6%19 8%

Assessing CHD Risk in Women

Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA.

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

Step 1: Age

YearsPoints

20-34 -735-39 -340-44 045-49 350-54 655-59 860-64 1065-69 1270-74 1475-79 16

TC Points at Points at Points at Points atPoints at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69

Age 70-79 <160 0 0 0 0

0160-199 4 3 2 1

1200-239 8 6 4 2

1240-279 11 8 5 3

2280 13 10 7 4

2

HDL-C(mg/dL) Points

60 -1

50-59 0

40-49 1

<40 2


Systolic BP PointsPoints

(mm Hg) if Untreated if Treated

<120 0 0120-129 1 3130-139 2 4140-159 3 5160 4 6

Step 4: Systolic Blood Pressure


Points at Points at Points at Points atPoints at

Age 20-39 Age 40-49 Age 50-59 Age 60-69Age 70-79

Nonsmoker 0 0 0 00

Smoker 9 7 4 21

Age

Total cholesterol

HDL-cholesterol


Smoking status

Point total

Step 6: Adding Up the Points

Step 7: CHD Risk



Men

Years Points20-34 -935-39 -440-44 045-49 350-54 655-59 860-64 1065-69 1170-74 1275-79 13

Step 1: Age

Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.

Women

Years Points20-34 -735-39 -340-44 045-49 350-54 655-59 860-64 1065-69 1270-74 1475-79 16



Note: TC and HDL-C values should be the average of at least two fasting lipoprotein measurements.


MenTC Points at Points at Points at Points at Points at

(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79

<160 0 0 0 0 0160-199 4 3 2 1 0200-239 7 5 3 1 0240-279 9 6 4 2 1280 11 8 5 3 1

Women TC Points at Points at Points at Points at Points at

(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79

<160 0 0 0 0 0160-199 4 3 2 1 1200-239 8 6 4 2 1240-279 11 8 5 3 2280 13 10 7 4 2



Note: HDL-C and TC values should be the average of at least two fasting lipoprotein measurements.


Men

HDL-C(mg/dL) Points

60 -1

50-59 0

40-49 1

<40 2

Women

HDL-C(mg/dL) Points

60 -1

50-59 0

40-49 1

<40 2


Step 4: Systolic Blood PressureMenSystolic BP Points Points(mm Hg) if Untreated if Treated

<120 0 0120-129 0 1130-139 1 2140-159 1 2160 2 3

WomenSystolic BP Points Points(mm Hg) if Untreated if Treated

<120 0 0120-129 1 3130-139 2 4140-159 3 5160 4 6



Note: Any cigarette smoking in the past month.


Men Points at Points at Points at Points at Points at

Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79

Nonsmoker 0 0 0 0 0

Smoker 8 5 3 1 1

Women Points at Points at Points at Points at Points at

Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79

Nonsmoker 0 0 0 0 0

Smoker 9 7 4 2 1


Step 6: Adding Up the Points(Sum From Steps 1–5)


AgeTotal cholesterol

HDL-cholesterol


Smoking status

Point total


© 2001, Professional Postgraduate Services®

www.lipidhealth.org

Step 7: CHD Risk for Men

Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total.


<0 <1% 11 8%0 1% 12 10%1 1% 13 12%2 1% 14 16%3 1% 15 20%4 1% 16 25%5 2% 17 30%6 2%7 3%8 4%9 5%

10 6%


Step 7: CHD Risk for Women

Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total.



<9 <1% 20 11%9 1% 21 14%

10 1% 22 17%11 1% 23 22%12 1% 24 27%13 2% 25 30%14 2%15 3%16 4%17 5%18 6%19 8%


Case History #1

• 46 y.o. man with type II diabetes, blood pressure, pressure 138/76, total cholesterol 195

• What other medical history information is needed?

• What other laboratory tests do you order?

• What are risk factor goals and recommended treatments?

Case History #2

• 50 y.o. female with past history of myocardial infarction, blood pressure 140/88, total cholesterol 190, HDL-cholesterol 35 from 6 mos ago.

• What other medical history would be helpful, what other lab tests do you order?

• What are risk factor goal levels, treatments needed or recommended?

Documents

LDL-C target levels (mg/dL) 2 RF: