Cholesterol (cont.)
What are the 2004 NCEP cholesterol treatment guidelines?
After reviewing
these large randomized cholesterol-lowering trials, The National Cholesterol
Education Program (NCEP) expert panel published their new recommendations. The
new NCEP recommendations, presented in the June, 2004 issue of Circulation, are:
- The report advised physicians to consider more intensive LDL cholesterol-lowering
for people at very high, high, and moderately high risk
for a heart attack. These options include setting lower treatment goals for
LDL cholesterol and initiating cholesterol-lowering drug therapy at lower
LDL thresholds, as compared to ATP III guidelines published in 2001. For
example, for patients with a very high risk of heart attacks, the LDL cholesterol treatment
goal remains at <100mg/dl, but the report advised doctors to consider
the option of lowering the LDL cholesterol (usually using a statin plus
lifestyle changes) to < 70 mg/dl.
- The report emphasized the importance of
initiating therapeutic lifestyle changes (TLC) to modify lifestyle-related risk
factors (obesity,
physical inactivity, metabolic syndrome, high blood triglyceride levels and
low HDL cholesterol levels). TLC Lifestyle changes have the potential to
reduce heart attack and stroke risks through several mechanisms beyond the
lowering of LDL cholesterol.
- When LDL-lowering medication is used for very high,
high or moderately high risk patients, the report advises that the intensity
of LDL-lowering drug therapy be sufficient to achieve at least a 30 to 40
percent reduction in LDL cholesterol levels.
- When a very high or high risk patient also has high
blood triglyceride or low HDL cholesterol levels, doctors may consider
combining nicotinic acid or a fibrate with a statin. Nicotinic acid and
fibrates are more effective than statins in lowering triglycerides and
increasing HDL.
- Age should not be a consideration since
older persons also benefit from lowering LDL cholesterol. Thus, it is never too
late or the patient too old to begin lifestyle changes and medications to lower
LDL cholesterol. A word of caution is in order. Elderly patients are more likely
to have liver and kidney dysfunction, and are also more likely to be on multiple
medications some of which may interfere with the breakdown of
cholesterol-lowering drugs such as statins. Thus lower dosing may be necessary
to avoid adverse side effects.
The 2004 NCEP treatment goals according
to risk categories
| Risk category |
LDL goal |
More intense LDL goal option |
Initiate TLC if LDL is: |
Consider drugs + TLC if LDL is: |
| High risk |
< 100 mg/dl |
|
> 100 mg/dl |
>100 mg/dl |
| Very high risk |
< 100 mg/dl |
< 70 mg/dl |
> 100 mg/dl |
<100 mg/dl |
| Moderately high risk (10 yr. risk 10-20%) |
<130 mg/dl |
<100 mg/dl |
> 130 mg/dl |
>130mg/dl, consider
drug option if LDL is 100-129 mg/dl |
| Moderate risk (10 yr. risk <10%) |
<130 mg/dl |
|
> 130 mg/dl |
>160 mg/dl |
| Lower risk |
<160 mg/dl |
|
> 160 mg/dl |
>190 mg/dl, consider
drug optional if LDL is 160-189 mg/dl |
- High risk patients are those who already
have coronary heart disease (such as a prior heart attack), diabetes mellitus,
abdominal aortic aneurysm, or
those who already have atherosclerosis of the arteries to the brain and
extremities (such as patients with strokes, TIA's (mini-strokes), and
peripheral vascular diseases). High risk patients also include those with 2 or
more risk factors (e.g., smoking, hypertension, or a family history of early
heart attacks) that places them at a greater than 20 percent chance of having
a heart attack within 10 years. (A person's chance of having a heart attack
can be calculated by using the Framingham Heart Study Score Sheets, at
http://nhlbi.nih.gov/about/framingham/riskabs.htm).
- Very
high -risk patients
are those who have coronary heart disease in addition to having either
multiple risk factors (especially diabetes), or severe and poorly controlled
risk factors (such as continued smoking), or metabolic syndrome (a
constellation of risk factors associated with obesity, including high
triglycerides and low HDL). Patients hospitalized for acute coronary syndromes
are also at very high risk.
- Moderately high risk
patients are those who have neither coronary heart disease nor diabetes
mellitus, but have multiple (2 or more) risk factors for coronary heart
disease that put them at a 10 to 20 percent risk of heart attack within 10
years. (Use the Framingham Heart Study Score Sheets, at
http://nhlbi.nih.gov/about/framingham/riskabs,htm to calculate the 10 year
risk.)
- Moderate risk patients
are those who have neither CHD nor diabetes mellitus, but have 2 or more risk
factors for coronary heart disease that put them at a <10% risk of heart
attack within 10 years.
- Lower risk
patients are those with 0 to 1 risk factor for coronary heart disease.
Next: Why is HDL the good cholesterol? »
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