Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)

ATP III At-A-Glance: Quick Desk Reference

Table of Contents

STEP 1:  Determine lipoprotein levels - obtain complete lipoprotein profile after 9- to 12-hour fast.

ATP III Classification of LDL, Total, and HDL Cholesterol (mg/dL)

STEP 2: Identify presence of clinical atherosclerotic disease that confers high risk for coronary heart disease (CHD) events (CHD risk equivalent):

STEP 3: Determine presence of major risk factors (other than LDL):

Major Risk Factors (Exclusive of LDL Cholesterol) That Modify LDL Goals

* HDL cholesterol greater than or equal to60 mg/dL counts as a "negative" risk factor; its presence removes one risk factor from the total count.

Note: in ATP III, diabetes is regarded as a CHD risk equivalent.

STEP 4: If 2+ risk factors (other than LDL) are present without CHD or CHD risk equivalent, assess 10-year (short-term) CHD risk (see Framingham tables).

Three levels of 10-year risk:

STEP 5: Determine risk category:

LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC) and Drug Therapy in Different Risk Categories.

Risk Category LDL Goal LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) LDL Level at Which to Consider Drug Therapy
CHD or CHD Risk Equivalents (10-year risk >20%) <100 mg/dL greater than or equal to100 mg/dL greater than or equal to130 mg/dL (100-129 mg/dL: drug optional)*
2+ Risk Factors (10-year risk less than or equal to20%) <130 mg/dL greater than or equal to130 mg/dL 10-year risk 10-20%: greater than or equal to130 mg/dL

10-year risk <10%: greater than or equal to160 mg/dL
0-1 Risk Factor** <160 mg/dL greater than or equal to160 mg/dL greater than or equal to190 mg/dL
(160-189 mg/dL: LDL-lowering drug optional)

* Some authorities recommend use of LDL-lowering drugs in this category if an LDL cholesterol <100 mg/dL cannot be achieved by therapeutic lifestyle changes. Others prefer use of drugs that primarily modify triglycerides and HDL, e.g., nicotinic acid or fibrate. Clinical judgment also may call for deferring drug therapy in this subcategory.

** Almost all people with 0-1 risk factor have a 10-year risk <10%, thus 10-year risk assessment in people with 0-1 risk factor is not necessary.

STEP 6: Initiate therapeutic lifestyle changes (TLC) if LDL is above goal.

TLC Features

STEP 7: Consider adding drug therapy if LDL exceeds levels shown in Step 5 table:

Drugs Affecting Lipoprotein Metabolism

Drug Class Agents and Daily Doses Lipid/Lipoprotein Effects Side Effects Contraindications
HMG CoA reductase inhibitors (statins) Lovastatin (20-80 mg), Pravastatin (20-40 mg), Simvastatin (20-80 mg), Fluvastatin (20-80 mg), Atorvastatin (10-80 mg), Cerivastatin (0.4-0.8 mg) LDL-C   lower by18-55%
HDL-C   raise by 5-15%
TG        lower by 7-30%
Increased liver enzymes
  • Active or chronic liver disease

  • Relative:
  • Concomitant use of certain drugs*
  • Bile acid Sequestrants Cholestyramine (4-16 g) Colestipol (5-20 g) Colesevelam (2.6-3.8 g) LDL-C   lower by15-30%
    HDL-C   raise by 3-5%
    TG        No change or increase
    Gastrointestinal distress
    Decreased absorption of other drugs
  • dysbeta-lipoproteinemia

  • TG >400 mg/dL

  • Relative:
  • TG >200 mg/dL
  • Nicotinic acid Immediate release (crystalline) nicotinic acid (1.5-3 gm), extended release nicotinic acid (Niaspan ®) (1-2 g), sustained release nicotinic acid (1-2 g) LDL-C   lower by 5-25%
    HDL-C   raise by15-35%
    TG       lower by20-50%
    Hyperuricemia (or gout)
    Upper GI distress
  • Chronic liver disease

  • Severe gout

  • Relative:
  • Diabetes

  • Hyperuricemia

  • Peptic ulcer disease
  • Fibric acids Gemfibrozil (600 mg BID)
    Fenofibrate (200 mg)
    Clofibrate (1000 mg BID)
    LDL-C   lower by 5-20% (may be increased in patients with high TG)
    HDL-C   raise by10-20%
    TG       lower by20-50%
  • Severe renal disease
  • Severe hepatic disease
  • * Cyclosporine, macrolide antibiotics, various anti-fungal agents, and cytochrome P-450 inhibitors (fibrates and niacin should be used with appropriate caution).

    STEP 8: Identify metabolic syndrome and treat, if present, after 3 months of TLC.

    Clinical Identification of the Metabolic Syndrome - Any 3 of the Following:

    Risk Factor Defining Level
    Abdominal obesity*
    Waist circumference**
     >102 cm (>40 in)
     >88 cm (>35 in)
    Triglycerides greater than or equal to150 mg/dL
    HDL cholesterol
    <40 mg/dl
    <50 mg/dl
    blood pressure greater than or equal to130/greater than or equal to85 mmHg
    Fasting glucose greater than or equal to110 mg/dL

    * Overweight and obesity are associated with insulin resistance and the metabolic syndrome. However, the presence of abdominal obesity is more highly correlated with the metabolic risk factors than is an elevated body mass index (BMI). Therefore, the simple measure of waist circumference is recommended to identify the body weight component of the metabolic syndrome.

    ** Some male patients can develop multiple metabolic risk factors when the waist circumference is only marginally increased, e.g., 94-102 cm (37-39 in). Such patients may have a strong genetic contribution to insulin resistance. They should benefit from changes in life habits, similarly to men with categorical increases in waist circumference.

    Treatment of the metabolic syndrome

    STEP 9: Treat elevated triglycerides.

    ATP III Classification of Serum Triglycerides (mg/dL)

    < 150 Normal
    150-199 Borderline high
    200-499 High
    greater than or equal to500 Very high

    Treatment of elevated triglycerides (greater than or equal to150 mg/dL)

    Comparison of LDL Cholesterol and Non-HDL Cholesterol Goals for Three Risk Categories

    Risk CategoryLDL Goal (mg/dL)Non-HDL Goal (mg/dL)
    CHD and CHD Risk Equivalent (10-year risk for CHD >20%) <100 <130
    Multiple (2+) Risk Factors and 10-year risk less than or equal to20% <130 <160
    0-1 Risk Factor<160 <190

    If triglycerides 200-499 mg/dL after LDL goal is reached, consider adding drug if needed to reach non-HDL goal:

    If triglycerides greater than or equal to500 mg/dL, first lower triglycerides to prevent pancreatitis:

    Treatment of low HDL cholesterol (<40 mg/dL)

    Public Health Service
    National Institutes of Health
    National Heart, Lung, and Blood Institute

    NIH Publication No. 01-3305
    May 2001 Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) NCEP Logo National Cholesterol Education Program

    Please send us your feedback, comments, and questions
    by using the appropriate link on the page, Contact the NHLBI.

    Note to users of screen readers and other assistive technologies: please report your problems here.