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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)

  • LDL Cholesterol - Primary Target of Therapy

    <100 Optimal
    100-129 Near Optimal/Above Optimal
    130-159 Borderline High
    160-189 High
    greater than or equal to190 Very high


  • Total Cholesterol

    <200 Desirable
    200-239 Borderline High
    greater than or equal to240 High


  • HDL Cholesterol

    <40 Low
    greater than or equal to60 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.

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

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

  • Cigarette smoking
  • Hypertension (BP greater than or equal to140/90 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 greater than or equal to45 years; women greater than or equal to55 years)
* 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:

  • >20% -- CHD risk equivalent
  • 10-20%
  • <10%

STEP 5: Determine risk category:

  • 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 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

  • 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

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

  • 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   lower by18-55%
HDL-C   raise by 5-15%
TG        lower by 7-30%
Myopathy
Increased liver enzymes
Absolute:
  • 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
Constipation
Decreased absorption of other drugs
Absolute:
  • 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%
Flushing
Hyperglycemia
Hyperuricemia (or gout)
Upper GI distress
Hepatotoxicity
Absolute:
  • 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%
Dyspepsia
Gallstones
Myopathy
Absolute:
  • 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*
 Men
 Women
Waist circumference**
 >102 cm (>40 in)
 >88 cm (>35 in)
Triglycerides greater than or equal to150 mg/dL
HDL cholesterol
 Men
 Women
<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

  • 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)

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)

  • Primary aim of therapy is to reach LDL goal.
  • Intensify weight management.
  • Increase physical activity.
  • If triglycerides are greater than or equal to200 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 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:

  • intensify therapy with LDL-lowering drug, or
  • add nicotinic acid or fibrate to further lower VLDL.

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

  • very low-fat diet (less than or equal to15% 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
May 2001

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