Table of Contents
- STEP 1: Determine lipoprotein levels - obtain complete lipoprotein profile after 9- to 12-hour fast
- 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)
- STEP 4: If 2+ risk factors (other than LDL) are present without CHD or CHD risk equivalent, assess 10-year (short-term) CHD risk
- STEP 5: Determine risk category
- STEP 6: Initiate therapeutic lifestyle changes (TLC) if LDL is above goal
- STEP 7: Consider adding drug therapy if LDL exceeds levels shown in Step 5 table
- STEP 8: Identify metabolic syndrome and treat, if present, after 3 months of TLC
- STEP 9: Treat elevated triglycerides
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)
- LDL Cholesterol - Primary Target of Therapy
<100 Optimal 100-129 Near Optimal/Above Optimal 130-159 Borderline High 160-189 High 190 Very high
- Total Cholesterol
<200 Desirable 200-239 Borderline High 240 High
- HDL Cholesterol
<40 Low 60 High
STEP 2: Identify presence of clinical atherosclerotic disease that confers high risk for coronary heart disease (CHD) events (CHD risk equivalent):
- Clinical CHD
- Symptomatic carotid artery disease
- Peripheral arterial disease
- Abdominal aortic aneurysm.
Major Risk Factors (Exclusive of LDL Cholesterol) That Modify LDL Goals
- Cigarette smoking
- Hypertension (BP 140/90 mmHg or on antihypertensive medication)
- Low HDL cholesterol (<40 mg/dl)*
- Family history of premature CHD (CHD in male first degree relative <55 years; CHD in female first degree relative <65 years)
- Age (men 45 years; women 55 years)
* HDL cholesterol 60 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:
- >20% -- CHD risk equivalent
- Establish LDL goal of therapy
- Determine need for therapeutic lifestyle changes (TLC)
- Determine level for drug consideration
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||100 mg/dL||130 mg/dL (100-129 mg/dL: drug optional)*|
|2+ Risk Factors (10-year risk 20%)||<130 mg/dL||130 mg/dL||10-year risk 10-20%:
10-year risk <10%: 160 mg/dL
|0-1 Risk Factor**||<160 mg/dL||160 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.
- TLC Diet:
- Saturated fat <7% of calories, cholesterol <200 mg/day
- Consider increased viscous (soluble) fiber (10-25 g/day) and plant stanols/sterols (2g/day) as therapeutic options to enhance LDL lowering
- Weight management
- Increased physical activity
- Consider drug simultaneously with TLC for CHD and CHD equivalents
- Consider adding drug to TLC after 3 months for other risk categories.
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
Increased liver enzymes
|Bile acid Sequestrants||Cholestyramine (4-16 g) Colestipol (5-20 g) Colesevelam (2.6-3.8 g)||LDL-C
TG No change or increase
Decreased absorption of other drugs
|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
Hyperuricemia (or gout)
Upper GI distress
|Fibric acids||Gemfibrozil (600 mg BID)
Fenofibrate (200 mg)
Clofibrate (1000 mg BID)
5-20% (may be increased in patients with high TG)
* Cyclosporine, macrolide antibiotics, various anti-fungal agents, and cytochrome P-450 inhibitors (fibrates and niacin should be used with appropriate caution).
Clinical Identification of the Metabolic Syndrome - Any 3 of the Following:
|Risk Factor||Defining Level|
>102 cm (>40 in)
>88 cm (>35 in)
|blood pressure||130/ 85 mmHg|
|Fasting glucose||110 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
- Treat underlying causes (overweight/obesity and physical inactivity):
- Intensify weight management
- Increase physical activity
- Treat lipid and non-lipid risk factors if they persist despite these lifestyle therapies:
- Treat hypertension
- Use aspirin for CHD patients to reduce prothrombotic state
- Treat elevated triglycerides and/or low HDL (as shown in Step 9 below)
ATP III Classification of Serum Triglycerides (mg/dL)
< 150 Normal 150-199 Borderline high 200-499 High 500 Very high
Treatment of elevated triglycerides ( 150 mg/dL)
- Primary aim of therapy is to reach LDL goal.
- Intensify weight management.
- Increase physical activity.
- If triglycerides are 200 mg/dL after LDL goal is reached, set secondary goal for non-HDL cholesterol (total - HDL) 30 mg/dL higher than LDL goal.
Comparison of LDL Cholesterol and Non-HDL Cholesterol Goals for Three Risk Categories
|Risk Category||LDL 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 20%||<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:
- intensify therapy with LDL-lowering drug, or
- add nicotinic acid or fibrate to further lower VLDL.
If triglycerides 500 mg/dL, first lower triglycerides to prevent pancreatitis:
- very low-fat diet ( 15% of calories from fat)
- weight management and physical activity
- fibrate or nicotinic acid
- when triglycerides <500 mg/dL, turn to LDL-lowering therapy.
Treatment of low HDL cholesterol (<40 mg/dL)
- First reach LDL goal, then:
- Intensify weight management and increase physical activity.
- If triglycerides 200-499 mg/dL, achieve non-HDL goal.
- If triglycerides <200 mg/dL (isolated low HDL) in CHD or CHD equivalent, consider nicotinic acid or fibrate.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
National Institutes of Health
National Heart, Lung, and Blood Institute
NIH Publication No. 01-3305