LDL-C target levels (mg/dL)  2 RF: <130 CHD:  100 % not at LDL-C targets  2 RFCHD Risk profile NHANES III L-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 of High Blood Cholesterol in Adults. JAMA. 2001;285:

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 of High Blood Cholesterol in Adults. JAMA. 2001;285:

ATP III: LDL-C, HDL-C, TC Classification Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285: High  240 Borderline high200–239 Desirable<200 TC (mg/dL) High  60 Low<40 HDL-C (mg/dL) Very high  190 High160–189 Borderline high130–159 Above, near optimal100–129 Optimal<100 LDL-C (mg/dL)

ATP III: Major CHD Risk Factors Other 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 factor and 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 diet Emerging 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 atheroscleroticproinflammatory 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 of High Blood Cholesterol in Adults. JAMA. 2001;285:

ATP III: Risk Categories, LDL-C Goals <1600–1 risk factor* <130  2 risk factors (10-year risk  20%) <100 CHD 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 of High Blood Cholesterol in Adults. JAMA. 2001;285:

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/dL 0–1 risk factor 10-year risk 10%–20%:  130 mg/dL 10-year risk  10%:  160 mg/dL  130 mg/dL  2 risk factors  130 mg/dL (100–129 mg/dL: drug optional) †  100 mg/dL CHD and CHD risk equivalents Consider Drug Therapy Initiate 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 to maintain 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 forms of 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 of High Blood Cholesterol in Adults. JAMA. 2001;285:

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  500 Very high †  weight,  physical activity, consider drug treatment to reach non–HDL-C goal ‡ 200–499High*  weight,  physical activity 150–199 Borderline high* Treatment StrategyTG Level (mg/dL)Classification

ATP III: The Metabolic Syndrome* <40 mg/dL <50 mg/dL Men Women >102 cm (>40 in) >88 cm (>35 in) Men Women  110 mg/dL Fasting glucose  130/  85 mm Hg Blood pressure HDL-C  150 mg/dL TG 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: Assessing CHD Risk in Men Step 1: Age YearsPoints Step 2: Total Cholesterol TC Points atPoints atPoints atPoints atPoints at (mg/dL) Age 20-39Age 40-49Age 50-59Age 60-69Age <  HDL-C (mg/dL) Points  <402 Step 3: HDL-Cholesterol Systolic BPPointsPoints (mm Hg)if Untreatedif Treated <  Step 4: Systolic Blood Pressure Step 5: Smoking Status Points atPoints atPoints atPoints atPoints at Age 20-39Age 40-49Age 50-59Age 60-69Age Nonsmoker00000 Smoker85311 Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total Step 6: Adding Up the Points Point Total10-Year RiskPoint Total10-Year Risk <0<1%118% 01%1210% 11%1312% 21%1416% 31%1520% 41%1625% 52%  17  30% 62% 73% 84% 95% 106% Step 7: CHD Risk ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ®

Point Total10-Year RiskPoint Total10-Year Risk <9<1%2011% 91%2114% 101%2217% 111%2322% 121%2427% 132%  25  30% 142% 153% 164% 175% 186% 198% 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: Step 1: Age YearsPoints TC Points atPoints atPoints atPoints atPoints at (mg/dL) Age 20-39Age 40-49Age 50-59Age 60-69Age <  HDL-C (mg/dL) Points  <402 Step 3: HDL-Cholesterol Systolic BPPointsPoints (mm Hg)if Untreatedif Treated <  Step 4: Systolic Blood Pressure Step 5: Smoking Status Points atPoints atPoints atPoints atPoints at Age 20-39Age 40-49Age 50-59Age 60-69Age Nonsmoker00000 Smoker97421 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 YearsPoints Step 1: Age Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285: Women YearsPoints 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 Blood Cholesterol in Adults. JAMA. 2001;285: Men TC Points atPoints atPoints atPoints atPoints at (mg/dL) Age 20-39Age 40-49Age 50-59Age 60-69Age <  Women TC Points atPoints atPoints atPoints atPoints at (mg/dL) Age 20-39Age 40-49Age 50-59Age 60-69Age <  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 Blood Cholesterol in Adults. JAMA. 2001;285: Men HDL-C (mg/dL) Points  <402 Women HDL-C (mg/dL) Points  <402 ATP III Framingham Risk Scoring

Step 4: Systolic Blood Pressure Men Systolic BPPointsPoints (mm Hg)if Untreatedif Treated <  Women Systolic BPPointsPoints (mm Hg)if Untreatedif Treated <  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 Blood Cholesterol in Adults. JAMA. 2001;285: Men Points atPoints atPoints atPoints atPoints at Age 20-39Age 40-49Age 50-59Age 60-69Age Nonsmoker00000 Smoker85311 Women Points atPoints atPoints atPoints atPoints at Age 20-39Age 40-49Age 50-59Age 60-69Age Nonsmoker00000 Smoker97421 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 Blood Cholesterol in Adults. JAMA. 2001;285: Age Total cholesterol HDL-cholesterol Systolic blood pressure Smoking status Point total ATP III Framingham Risk Scoring © 2001, Professional Postgraduate Services ®

Step 7: CHD Risk for Men Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total. Point Total10-Year RiskPoint Total10-Year Risk <0<1%118% 01%1210% 11%1312% 21%1416% 31%1520% 41%1625% 52%  17  30% 62% 73% 84% 95% 106% 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 Blood Cholesterol in Adults. JAMA. 2001;285: Point Total10-Year RiskPoint Total10-Year Risk <9<1%2011% 91%2114% 101%2217% 111%2322% 121%2427% 132%  25  30% 142% 153% 164% 175% 186% 198% 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?