# Presentation: 489222

## Perspectives and Guidelines

**National Heart, Lung, and Blood Institute**
**National Cholesterol Education Program**

## National Cholesterol Education Program Coordinating Committee

- Agency for Healthcare Research and Quality
- American Academy of Family Physicians
- American Academy of Insurance Medicine
- American Academy of Pediatrics
- American Association of Occupational Health Nurses
- American Association of Office Nurses
- American College of Cardiology
- American College of Chest Physicians
- American College of Nutrition
- American College of Obstetricians and Gynecologists
- American College of Occupational and Environmental Medicine
- American College of Preventive Medicine

- American Diabetes Association, Inc.
- American Dietetic Association
- American Heart Association
- American Hospital Association
- American Medical Association
- American Nurses Association
- American Osteopathic Association
- American Pharmaceutical Association
- American Public Health Association
- American Red Cross
- Association of Black Cardiologists
- Association of State and Territorial Health Officials
- Centers for Disease Control and Prevention
- Citizens for Public Action on Blood Pressure and Cholesterol, Inc.
- Coordinating Committee for the Community Demonstration Studies

- Health Resources and Services Administration
- National Black Nurses Association, Inc.
- National Cancer Institute
- National Center for Health Statistics
- National Heart, Lung, and Blood Institute
- National Medical Association
- NHLBI Ad Hoc Committee on Minority Populations
- Office of Disease Prevention and Health Promotion
- Society for Nutrition Education
- Society for Public Health Education
- U.S. Department of Agriculture
- U.S. Department of Defense
- U.S. Department of Veterans Affairs (VA)
- U.S. Food and Drug Administration

## CHD Outcomes in Clinical Trials of LDL Cholesterol-Lowering Therapy

**	**** ****No. ****	**** No. ****	**** Person-****	**** cholesterol ****	**** Incidence ****	**** Mortality **
**Intervention****	****trials****	****treated****	****years****	****reduction (%)****	**** (% change)****	****(% change)**
- Surgery	1	421	4,084	22	**-43**	-30
- Sequestrants	3	1,992	14,491	9	**-21**	-32
- Diet	6	1,200	6,356	11	**-24**	-21
- Statins	12	17,405	89,123	20	**-30**	**-29**
- Source: This table is adapted from the meta-analysis of Gordon, 2000.

**CHD Outcomes in Clinical Trials of ****LDL Cholesterol-Lowering Therapy**

## Risk Assessment

_**Count major risk factors**_
- For patients with multiple (2+) risk factors
- Perform 10-year risk assessment
- For patients with 0–1 risk factor
- 10 year risk assessment not required
- Most patients have 10-year risk <10%

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

**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.

## Diabetes

- In ATP III, diabetes is regarded as a CHD risk equivalent.

## CHD Risk Equivalents

- Risk for major coronary events equal to that in established CHD
- 10-year risk for hard CHD >20%

- Hard CHD = myocardial infarction + coronary death

## Diabetes as a CHD Risk Equivalent

- 10-year risk for CHD  20%
- High mortality with established CHD
- 	High mortality with acute MI
- 	High mortality post acute MI

## CHD Risk Equivalents

- Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and carotid artery disease [symptomatic or >50% stenosis])
- Diabetes
- Multiple risk factors that confer a 10-year risk for CHD >20%

## Risk Category
CHD and CHD riskequivalents

Multiple (2+) risk factors

Zero to one risk factor

- CHD and CHD riskequivalents
- Multiple (2+) risk factors
- Zero to one risk factor

_**LDL Goal (mg/dL)**_
**	****	**<100
- 		<130
- 		<160

**Three Categories of Risk that Modify ****LDL-Cholesterol Goals**

## LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC)and Drug Therapy in Different Risk Categories

| Risk Category | LDL Goal(mg/dL) | LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL) | LDL Level at Which to ConsiderDrug Therapy (mg/dL) |
| --- | --- | --- | --- |
| CHD or CHD Risk Equivalents(10-year risk >20%) | <100 | 100 | 130 (100–129: drug options) |
| 2+ Risk Factors (10-year risk 20%) | <130 | 130 | 10-year risk 10–20%: 130

10-year risk <10%: 160  |
| 0–1 Risk Factor | <160 | 160 | 190 (160–189: LDL-lowering drug optional) |

## LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC)and Drug Therapy in Different Risk Categories

| Risk Category | LDL Goal(mg/dL) | LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL) | LDL Level at Which to ConsiderDrug Therapy (mg/dL) |
| --- | --- | --- | --- |
| CHD or CHD Risk Equivalents(10-year risk >20%) | <100
(optional goal: <70) | 100 | 100 (<100: drug options) |
| 2+ Risk Factors (10-year risk 20%) | <130 | 130 | 10-year risk 10–20%: 130 (100-129: drug options)

10-year risk <10%: 160  |
| 0–1 Risk Factor | <160 | 160 | 190 (160–189: LDL-lowering drug optional) |

## Therapeutic Lifestyle Changes in LDL-Lowering Therapy

_**Major Features**_
- TLC Diet
- Reduced intake of cholesterol-raising nutrients (same as previous Step II Diet)
- Saturated fats <7% of total calories
- Dietary cholesterol <200 mg per day
- LDL-lowering therapeutic options
- Plant stanols/sterols (2 g per day)
- Viscous (soluble) fiber (10–25 g per day)
- Weight reduction
- Increased physical activity

## Benefit Beyond LDL Lowering: The Metabolic Syndrome as a Secondary Target of Therapy

_**General Features of the Metabolic Syndrome**_
- Abdominal obesity
- Atherogenic dyslipidemia
- 	Elevated triglycerides
- 	Small LDL particles
- 	Low HDL cholesterol
- Raised blood pressure
- Insulin resistance ( glucose intolerance)
- Prothrombotic state
- Proinflammatory state

## Diagnosis of the Metabolic Syndrome

- Any 3 of the following:
- Waist circumference >40 inches (men), >35 inches (women)
- Triglycerides 150 mg/dL
- HDL <40 mg/dL (men), <50 mg/dL (women)
- BP 130/85 mm Hg
- Fasting glucose _>_100 mg/dL

## Metabolic Syndrome (continued)

_**Therapeutic Objectives**_
- To reduce underlying causes
- Overweight and obesity
- Physical inactivity
- To treat associated lipid and non-lipid risk factors
- Hypertension
- Prothrombotic state
- Atherogenic dyslipidemia (lipid triad)

## Slide 17