Transcript mg/dL

Adult Population Not Reaching LDL-C
Targets
100
80
NHANES III
L-TAP
82.5
82
63
% not at
LDL-C
targets
60
54.6
40
20
0
2 RF
CHD
Risk profile
LDL-C target levels (mg/dL)
2 RF: <130
CHD: 100
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;285:2486-2497.
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 of
High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
ATP III: LDL-C, HDL-C, TC
Classification
LDL-C (mg/dL)
<100
100–129
130–159
160–189
190
HDL-C (mg/dL)
<40
60
TC (mg/dL)
<200
200–239
240
Optimal
Above, near optimal
Borderline high
High
Very high
Low
High
Desirable
Borderline high
High
Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
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 riskreduction therapy; do not categorically alter LDL-C
goals
– lipoprotein(a)
– impaired fasting glucose
– subclinical atherosclerotic
factors
– homocysteine
– prothrombotic and
proinflammatory
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;285:2486-2497.
ATP III: Risk Categories, LDL-C
Goals
Risk Category
CHD and CHD risk equivalents
(10-year risk >20%)
2 risk factors
(10-year risk 20%)
0–1 risk factor*
LDL-C Goal (mg/dL)
<100
<130
<160
*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;285:2486-2497.
ATP III: LDL-C Treatment Cutpoints for
Therapy
Risk Category
Initiate
TLC*
Consider Drug Therapy
CHD and CHD
risk equivalents
100 mg/dL
2 risk factors
130 mg/dL 10-year risk 10%–20%: 130 mg/dL
0–1 risk factor
160 mg/dL
130 mg/dL
(100–129 mg/dL: drug optional)†
10-year risk 10%: 160 mg/dL
190 mg/dL
(160–189 mg/dL: LDL-C–lowering
drug optional)
*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.
ATP III: Nutritional Components of the TLC Diet
Nutrient
Recommended Intake
Saturated fat*
<7% of total calories
Polyunsaturated fat
Up to 10% of total calories
Monounsaturated fat
Up to 20% of total calories
Total fat
25%–35% of total calories
Carbohydrate(esp.complex carbs) 50%–60% of total calories
Fiber
20–30 g/d
Protein
~15% of total calories
Cholesterol
<200 mg/d
*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.
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;285:2486-2497.
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
Classification
TG Level (mg/dL)
Treatment Strategy
Borderline high*
150–199
 weight, physical activity
High*
200–499
 weight, physical activity,
consider drug treatment to
reach non–HDL-C goal‡
Very high†
500
Very low-fat diet,  weight,
physical activity, nicotinic
acid or fibrate
ATP III: The Metabolic Syndrome*
Risk Factor
Abdominal obesity†
(Waist circumference‡)
Men
Women
TG
HDL-C
Men
Women
Blood pressure
Fasting glucose
Defining Level
>102 cm (>40 in)
>88 cm (>35 in)
150 mg/dL
<40 mg/dL
<50 mg/dL
130/85 mm Hg
110 mg/dL
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
ATP III Framingham Risk Scoring
Step 1: Age
Years
20-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
Assessing CHD Risk in Men
Step 4: Systolic Blood Pressure
Points
-9
-4
0
3
6
8
10
11
12
13
Systolic BP
(mm Hg)
<120
120-129
130-139
140-159
160
Points
Points
if Untreated if Treated
0
0
0
1
1
2
1
2
2
3
HDL-C
(mg/dL)
60
Points
-1
50-59
0
40-49
1
<40
2
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
Step 7: CHD Risk
Step 2: Total Cholesterol
TC
Points at
at Points at
(mg/dL)
Age 20-39
70-79
<160
0
160-199
4
200-239
7
240-279
9
280
11
Step 3: HDL-Cholesterol
Step 6: Adding Up the Points
Points at
Points at
Points
Age 40-49 Age 50-59 Age 60-69 Age
0
3
5
6
8
0
2
3
4
5
0
1
1
2
3
0
0
0
1
1
Step 5: Smoking Status
at
70-79
Nonsmoker
the
experience
Smoker
Points at
Points at
Age 20-39
0
Points at
Point Total 10-Year Risk
Risk
<0
<1%
0
1%
1
1%
2
1%
3
1%
4
1%
5
2%
6
2%
7
3%
8
4%
9
5%
10
6%
Points at
Point Total 10-Year
11
12
13
14
15
16
17
8%
10%
12%
16%
20%
25%
30%
Points
Age 40-49 Age 50-59 Age 60-69 Age
0
0
Note: Risk estimates were derived from
of the8 Framingham 5Heart Study, 3
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.
0
0
1 2001,
1
©
Professional
Postgraduate Services®
www.lipidhealth.org
ATP III Framingham Risk Scoring
Assessing CHD Risk in Women
Step 1: Age
Years
20-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
Step 4: Systolic Blood Pressure
Points
-7
-3
0
3
6
8
10
12
14
16
Systolic BP
(mm Hg)
<120
120-129
130-139
140-159
160
Points
Points
if Untreated if Treated
0
0
1
3
2
4
3
5
4
6
50-59
0
40-49
1
<40
2
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
Step 7: CHD Risk
Step 2: Total Cholesterol
TC
Points at
at Points at
(mg/dL)
Age 20-39
70-79
<160
0
160-199
4
200-239
8
240-279
11
Step 3: HDL-Cholesterol
280
13
HDL-C
(mg/dL)
Points
60
-1
Step 6: Adding Up the Points
Points at
Points at
Points
Age 40-49 Age 50-59 Age 60-69 Age
0
3
6
8
10
0
2
4
5
7
0
1
2
3
4
0
1
1
2
2
Step 5: Smoking Status
at
70-79
Nonsmoker
Smoker
Points at
Points at
Age 20-39
0
9
Points at
Point Total 10-Year Risk
Risk
<9
<1%
9
1%
10
1%
11
1%
12
1%
13
2%
14
2%
15
3%
16
4%
17
5%
18
6%
19
8%
Points at
Point Total 10-Year
20
21
22
23
24
25
11%
14%
17%
22%
27%
30%
Points
Age 40-49 Age 50-59 Age 60-69 Age
0
7
0
4
0
2
0
1
Note: Risk estimates were derived from the experience of the
Framingham Heart Study, a predominantly Caucasian population
in Massachusetts, USA.
ATP III Framingham Risk Scoring
Step 1: Age
Women
Men
Years
20-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
Points
-9
-4
0
3
6
8
10
11
12
13
Years
20-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
Points
-7
-3
0
3
6
8
10
12
14
16
Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults. JAMA. 2001;285:2486-2497.
ATP III Framingham Risk Scoring
Step 2: Total Cholesterol
Men
TC
(mg/dL)
Points at
Age 20-39
Points at
Age 40-49
Points at
Age 50-59
Points at
Age 60-69
Points at
Age 70-79
<160
160-199
200-239
240-279
280
0
4
7
9
11
0
3
5
6
8
0
2
3
4
5
0
1
1
2
3
0
0
0
1
1
Women
TC
(mg/dL)
Points at
Age 20-39
Points at
Age 40-49
Points at
Age 50-59
Points at
Age 60-69
Points at
Age 70-79
<160
160-199
200-239
240-279
280
0
4
8
11
13
0
3
6
8
10
0
2
4
5
7
0
1
2
3
4
0
1
1
2
2
Note: TC and HDL-C values should be the average of at least two fasting
lipoprotein measurements.
ATP III Framingham Risk Scoring
Step 3: HDL-Cholesterol
Women
Men
HDL-C
(mg/dL)
Points
60
HDL-C
(mg/dL)
Points
-1
60
-1
50-59
0
50-59
0
40-49
1
40-49
1
<40
2
<40
2
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;285:2486-2497.
ATP III Framingham Risk Scoring
Step 4: Systolic Blood Pressure
Men
Systolic BP Points
Points
(mm Hg)if Untreatedif Treated
<120
0
0
120-129
0
1
130-139
1
2
140-159
1
2
160
2
3
Women
Systolic BP
Points
(mm Hg) if Untreated
<120
120-129
130-139
140-159
160
0
1
2
3
4
Points
if Treated
0
3
4
5
6
ATP III Framingham Risk Scoring
Men
Step 5: Smoking Status
Points at
Points at
Age 20-39 Age 40-49
Nonsmoker
Smoker
0
8
0
5
Points at
Age 50-59
Points at
Age 60-69
Points at
Age 70-79
0
3
0
1
0
1
Points at
Age 50-59
Points at
Age 60-69
Points at
Age 70-79
0
4
0
2
0
1
Women
Points at
Points at
Age 20-39 Age 40-49
Nonsmoker
Smoker
0
9
0
7
Note: Any cigarette smoking in the past month.
Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults. JAMA. 2001;285:2486-2497.
ATP III Framingham Risk Scoring
Step 6: Adding Up the Points
(Sum From Steps 1–5)
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Smoking status
Point total
Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults. JAMA. 2001;285:2486-2497.
© 2001, Professional Postgraduate Services®
www.lipidhealth.org
ATP III Framingham Risk Scoring
Step 7: CHD Risk for Men
Point Total
10-Year Risk
Point Total
10-Year Risk
<0
0
1
2
3
4
5
6
7
8
9
10
<1%
1%
1%
1%
1%
1%
2%
2%
3%
4%
5%
6%
11
12
13
14
15
16
17
8%
10%
12%
16%
20%
25%
30%
Note: Determine the 10-year absolute risk for hard
CHD (MI and coronary death) from point total.
ATP III Framingham Risk Scoring
Step 7: CHD Risk for Women
Point Total
10-Year Risk
Point Total
10-Year Risk
<9
9
10
11
12
13
14
15
16
17
18
19
<1%
1%
1%
1%
1%
2%
2%
3%
4%
5%
6%
8%
20
21
22
23
24
25
11%
14%
17%
22%
27%
30%
Note: Determine the 10-year absolute risk for hard CHD
(MI and coronary death) from point total.
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, HDLcholesterol 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?