The Helena Cardiology Clinic
(aka; Last Chance Cardiology)
32 Medical Park Drive
Helena, Montana 59601

The National Cholesterol Education Program (NCEP) has issued new guidelines for the prevention and management of elevated cholesterol in adults called the Adult Treatment Panel (ATP) III. The first two reports set the frameworks for primary prevention of coronary heart disease (CHD) in individuals with elevated LDL-C levels and multiple risk factors as well as the intensive management of LDL-C in those with existing CHD. ATP III expands on these and goes a step further by focusing more on primary prevention in those with multiple risk factors. ATP III builds on previous reports that were released in 1988 and 1993 and is published in the May 16 issue of the Journal of the American Medical Association (2001; 285:2486-97).

Based on recent research and clinical trial data, LDL cholesterol is the primary target of therapy.

More aggressive cholesterol-lowering therapy and better identification of individuals at elevated risk for coronary heart disease (CHD).

The use of a 9-12 hour fasting lipoprotein profile as the first test for high cholesterol levels.

A new level at which low HDL cholesterol becomes a major risk factor for CHD (<40 mg/dl).

A new set of Therapeutic Lifestyle Changes (TLC)

More intense focus on the metabolic syndrome and increased attention to treating high triglycerides

In the new guidelines, diabetes in primary prevention is raised to a CHD risk equivalent because of the high risk it confers for CHD within ten years. This is primarily due to the fact that the condition is frequently associated with multiple risk factors. Also, patients with diabetes who and experience myocardial infarction have "an unusually high death rate."

The new guidelines include a risk assessment tool based on newly analyzed data from the Framingham Heart Study. The tool allows clinicians to translated clinical conditions and lifestyle factors into a single category of 10-year risk (separate for men and women).

Therapeutic Lifestyle Change, a lifestyle approach, is recommended to lower cholesterol level and decrease the risk of heart disease. Features include reduced intake of saturated fats and cholesterol; use of foods that contain plant stanols and sterols or are rich in soluble fiber; weight reduction; and increased physical activity.

For primary prevention, ATP III noted that the first priority of drug therapy is achieving LDL goals; the usual drug will be a statin but alternatives include a bile acid sequestrant or nicotinic acid. The guidelines recommend against the use of hormone replacement therapy as an alternative to cholesterol-lowering drugs in postmenopausal women.

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

LDL Cholesterol - Primary Target of Therapy

 

< 100	Optimal
100-129	Near/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.

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

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 and 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

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

* 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 judgement also may call for deferring drug therapy in this subcategory.

+ Almost all people with 0-1 risk factor have a 10-year risk <10%, this 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 < 200mg/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 equivalent

Consider adding drug to TLC after 3 months for other risk categories.

§ HMG CoA reductase inhibitors (statins)

w Lovastatin

w Pravastatin

w Simvastatin

w Fluvastatin

w Atorvastatin

w Cerivastatin

§ Bile acid sequestrants

w Cholestyramine

w Colestipol

w Colesevelam

§ Nicotinic Acid

w Niaspan

§ Fibric Acids

w Gemfibrozil

w Fenofibrate

w Clofibrate

Treatment of the Metabolic Syndrome

Treat underlying causes (overweight/obesity and physical inactivity):

Intensity weight management

Increase physical activity

Treat lipid and non-lipid risk factors if they persist despite these lifestyle therapies:

Treat hypertension

Use aspirin therapy for CHD patients to reduce prothrombotic state

Treat elevated triglycerides and/or low HDL (as shown in Step 9).

Step 9: Treat elevated triglycerides.

ATP III Classification of Serum Triglycerides (mg/dL)

 

< 150 150-199 200-499 > 500

Normal Borderline high High Very High

Treatment of elevated triglycerides (> 150 mg/dL) · Primary aim is to reach LDL goal · Intensity 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

First reach LDL goal, then:

Intensity weight management and increase physical actively

If triglycerides 200-499 mg/dl, achieve non-HDL goal

If triglyceride < 200 mg/dl (isolated low HDL) in CHD or CHD equivalent consider nicotinic acid of fibrate.