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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)
Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
ATP III: LDL-C, HDL-C, TC Classification
Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
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.
Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
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.
Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
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
Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
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
Point Total 10-Year Risk Point Total 10-Year Risk
<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
Step 3: HDL-Cholesterol
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
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 9 7 4 21
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
Step 6: Adding Up the Points
Step 7: CHD Risk
Step 2: Total Cholesterol
ATP III Framingham Risk Scoring
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
ATP III Framingham Risk Scoring
Step 2: Total Cholesterol
Note: TC and HDL-C values should be the average of at least two fasting lipoprotein measurements.
Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
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
ATP III Framingham Risk Scoring
Step 3: HDL-Cholesterol
Note: HDL-C and TC values should be the average of at least two fasting lipoprotein measurements.
Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
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
ATP III Framingham Risk Scoring
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
ATP III Framingham Risk Scoring
Step 5: Smoking Status
Note: Any cigarette smoking in the past month.
Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
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
ATP III Framingham Risk Scoring
Step 6: Adding Up the Points(Sum From Steps 1–5)
Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
AgeTotal cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
ATP III Framingham Risk Scoring
© 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.
Point Total 10-Year Risk Point Total 10-Year Risk
<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%
ATP III Framingham Risk Scoring
Step 7: CHD Risk for Women
Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total.
Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.
Point Total 10-Year Risk Point Total 10-Year Risk
<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%
ATP III Framingham Risk Scoring
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?
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