United states cholesterol guidelines 2001: expanded scope of intensive low-density lipoprotein–lowering therapy
Section snippets
Three risk categories: the key to defining intensity of low-density lipoprotein–lowering therapy
As previously mentioned, ATP III identifies LDL-C as the primary target of therapy in patients with, or at risk of, CHD. The intensity of LDL-C–lowering therapy and goals of therapy are modified according to the absolute risk of patients. Thus, risk assessment is an essential element of ATP III. The first aim of risk assessment is to divide patients into 3 categories of risk: (1) high risk, (2) intermediate (moderately high) risk, and (3) long-term risk.
The first 2 categories relate to
Risk assessment
To categorize a person’s level of risk, it is necessary to conduct risk assessment. This assessment is performed by (1) cardiovascular evaluation, (2) testing for diabetes, (3) identification of risk factors for CHD, and in some patients (4) formal global risk estimation. Each of these methods of assessment can be reviewed briefly.
Cardiovascular evaluation first searches for the presence of CHD, which is defined as follows: (1) history of myocardial infarction, (2) history of either stable or
Therapeutic lifestyle changes
First-line therapy for patients entering cholesterol management is modification of life habits. These modifications include cessation of cigarette smoking, LDL-C–lowering dietary changes, weight management, and increased physical activity. LDL-C–lowering dietary changes consist of the following: (1) reduction in intake of saturated fatty acids to <7% of total calories, (2) reduction of intake of dietary cholesterol to <200 mg/day, (3) addition of plant stanol/sterols at a level of 2 g/day, and
Management of high-risk patients
There are 2 types of patients that can be classified as high risk: (1) patients with established CHD, and (2) those with CHD risk equivalents. The latter represents a risk for major coronary events (hard CHD) equivalent to that of patients with established CHD. Follow-up study of persons with established CHD reveals that 10-year risk for future major coronary events (myocardial infarction plus coronary death) is >20%. Therefore, a CHD risk equivalent is defined as a 10-year risk for hard CHD of
Management of intermediate-risk (moderately high risk) patients
Patients in this category have multiple (≥2) risk factors and a 10-year risk for CHD of 10% to 20%. ATP III intensifies therapy in this risk category compared with previous ATP reports because of evidence from primary prevention trials showing benefit of LDL-C–lowering therapy.15, 16 The goal of therapy in intermediate-risk patients is an LDL-C level of <3.4 mmol/L (130 mg/dL). First-line management is therapeutic lifestyle changes with emphasis on LDL-C–lowering dietary therapy. However, if
Management of persons at long-term risk
Persons in the category of long-term risk include those with either multiple risk factors or categorical hypercholesterolemia (LDL-C ≥4.1 mmol/L [160 mg/dL]) whose 10-year risk for CHD is <10%. There are 4 types of patients with 10-year risk <10% who are specified as being at long-term risk, namely, those with: (1) multiple (≥2) risk factors (LDL-C 3.4 to 4.1 mmol/L [130 to 159 mg/dL], LDL-C ≥4.1 mmol/L [160 mg/dL]); and (2) 0 to 1 risk factor (LDL-C 4.1 to 4.9 mmol/L [160 to 189 mg/dL], LDL-C
Treatment of the metabolic syndrome: benefit beyond reduction of low-density lipoprotein cholesterol
The metabolic syndrome is characterized by multiple metabolic risk factors occurring in a patient. Important underlying causes are overweight/obesity and physical inactivity. Because of the increasing prevalence of these underlying risk factors, the metabolic syndrome is becoming increasingly common in the United States and worldwide. The metabolic syndrome increases risk for CHD beyond that produced by elevated LDL-C. For this reason, ATP III identifies the metabolic syndrome as an important
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