ATP III Guidelines At-A-Glance Quick Desk Reference

Determine lipoprotein levels–obtain complete lipoprotein profile after

9- to 12-hour fast.

ATP III Classification of LDL, Total, and HDL Cholesterol (mg/dL)

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.

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

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

■ Note: in ATP III, diabetes is regarded as a CHD risk equivalent.

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.

NATIONAL INSTITUTES OF HEALTH

NATIONAL HEART, LUNG, AND BLOOD INSTITUTE

National Cholesterol Education Program

High Blood Cholesterol

ATP III Guidelines At-A-Glance

Quick Desk Reference

LDL Cholesterol – Primary Target of Therapy

<100 Optimal

100-129 Near optimal/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 1

Step 2

Step 3

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%

Determine risk category:

■ Establish LDL goal of therapy

■ Determine need for therapeutic lifestyle changes (TLC)

■ Determine level for drug consideration

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

Risk Categories.

Initiate therapeutic lifestyle changes (TLC) if LDL is above goal.

LDL Level at Which

to Initiate Therapeutic LDL Level at Which to

Risk Category LDL Goal Lifestyle Changes (TLC) Consider Drug Therapy

CHD or CHD Risk Equivalents <100 mg/dL >

100 mg/dL >130 mg/dL

(10-year risk >20%) (100-129 mg/dL: drug optional)*

10-year risk 10-20%:

130 mg/dL

10-year risk <10%:

160 mg/dL

0-1 Risk Factor

†

<160 mg/dL >160 mg/dL >190 mg/dL

(160-189 mg/dL: LDL-lowering

drug optional)

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

† Almost all people with 0-1 risk factor have a 10-year risk <10%, thus 10-year risk assessment in people with 0-1 risk factor is

not necessary.

■ TLC Diet:

— Saturated fat <7% of calories, cholesterol <200 mg/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 4

Step 5

Step 6

TLC Features

2+ Risk Factors <130 mg/dL >

130 mg/dL

(10-year risk <

20%)

Consider adding drug therapy if LDL exceeds levels shown in Step 5 table:

■ Consider drug simultaneously with TLC for CHD and CHD equivalents

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

Drugs Affecting Lipoprotein Metabolism

Drug Class Agents and Lipid/Lipoprotein Side Effects Contraindications

Daily Doses Effects

Step 7

HMG CoA reductase

inhibitors (statins)

Bile acid sequestrants

Nicotinic acid

Fibric acids

Lovastatin (20-80 mg)

Pravastatin (20-40 mg)

Simvastatin (20-80 mg)

Fluvastatin (20-80 mg)

Atorvastatin (10-80 mg)

Cerivastatin (0.4-0.8 mg)

Cholestyramine (4-16 g)

Colestipol (5-20 g)

Colesevelam (2.6-3.8 g)

Immediate release

(crystalline) nicotinic acid

(1.5-3 gm), extended

release nicotinic acid

(Niaspan

) (1-2 g),

sustained release

nicotinic acid (1-2 g)

Gemfibrozil

(600 mg BID)

Fenofibrate (200 mg)

Clofibrate

(1000 mg BID)

Myopathy

Increased liver

enzymes

Gastrointestinal

distress

Constipation

Decreased absorp-

tion of other drugs

Flushing

Hyperglycemia

Hyperuricemia

(or gout)

Upper GI distress

Hepatotoxicity

Dyspepsia

Gallstones

Myopathy

Absolute:

• Active or chronic

liver disease

Relative:

• Concomitant use of

certain drugs*

Absolute:

• dysbeta-

lipoproteinemia

• TG >400 mg/dL

Relative:

• TG >200 mg/dL

Absolute:

• Chronic liver disease

• Severe gout

Relative:

• Diabetes

• Hyperuricemia

• Peptic ulcer disease

Absolute:

• Severe renal disease

• Severe hepatic

disease

LDL ↓18-55%

HDL ↑5-15%

TG ↓7-30%

LDL ↓15-30%

HDL ↑3-5%

TG No change

or increase

LDL ↓5-25%

HDL ↑15-35%

TG ↓20-50%

LDL ↓5-20%

(may be increased in

patients with high TG)

HDL ↑10-20%

TG ↓20-50%

* Cyclosporine, macrolide antibiotics, various anti-fungal agents, and cytochrome P-450 inhibitors (fibrates and niacin should be used with

appropriate caution).

Identify metabolic syndrome and treat, if present, after 3 months of TLC.

Clinical Identification of the Metabolic Syndrome – Any 3 of the Following:

Treatment of the metabolic syndrome

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

– Intensify weight management

– Increase physical activity.

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

– Treat hypertension

– Use aspirin for CHD patients to reduce prothrombotic state

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

Step 8

Risk Factor

Abdominal obesity*

Men

Women

Triglycerides

HDL cholesterol

Men

Women

Blood pressure

Fasting glucose

Defining Level

Waist circumference

†

>102 cm (>40 in)

>88 cm (>35 in)

150 mg/dL

<40 mg/dL

<50 mg/dL

130/>85 mmHg

110 mg/dL

* Overweight and obesity are associated with insulin resistance and the metabolic syndrome.

However, the presence of abdominal obesity is more highly correlated with the metabolic risk

factors than is an elevated body mass index (BMI). Therefore, the simple measure of waist cir-

cumference is recommended to identify the body weight component of the metabolic syndrome.

† Some male patients can develop multiple metabolic risk factors when the waist circumference is

only marginally increased, e.g., 94-102 cm (37-39 in). Such patients may have a strong genetic

contribution to insulin resistance. They should benefit from changes in life habits, similarly to

men with categorical increases in waist circumference.

Treat elevated triglycerides.

If triglycerides 200-499 mg/dL after LDL goal is reached, consider adding drug if needed to

reach non-HDL goal:

• intensify therapy with LDL-lowering drug, or

• add nicotinic acid or fibrate to further lower VLDL.

If triglycerides >

500 mg/dL, first lower triglycerides to prevent pancreatitis:

• very low-fat diet (<15% of calories from fat)

• weight management and physical activity

• fibrate or nicotinic acid

• when triglycerides <500 mg/dL, turn to LDL-lowering therapy.

Treatment of low HDL cholesterol (<40 mg/dL)

■ First reach LDL goal, then:

■ Intensify weight management and increase physical activity

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

■ If triglycerides <200 mg/dL (isolated low HDL) in CHD or CHD equivalent

consider nicotinic acid or fibrate.

Step 9

ATP III Classification of Serum Triglycerides (mg/dL)

<150 Normal

150-199 Borderline high

200-499 High

≥500 Very high

Treatment of elevated triglycerides (≥150 mg/dL)

■ Primary aim of therapy is to reach LDL goal

■ Intensify 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

Risk Category LDL Goal (mg/dL) Non-HDL Goal (mg/dL)

CHD and CHD Risk Equivalent <100 <130

(10-year risk for CHD >20%)

Multiple (2+) Risk Factors and <130 <160

10-year risk <

20%

0-1 Risk Factor <160 <190

Point Total 10-Year Risk %

< 9 < 1

10 1

11 1

12 1

13 2

14 2

15 3

16 4

17 5

18 6

19 8

20 11

21 14

22 17

23 22

24 27

≥25 ≥ 30

Point Total 10-Year Risk %

<0 < 1

10 6

11 8

12 10

13 12

14 16

15 20

16 25

≥17 ≥ 30

<160 0 0 0 0 0

160-199 4 3 2 1 0

200-239 7 5 3 1 0

240-279 9 6 4 2 1

≥280 11 8 5 3 1

Total

Cholesterol

Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79

Total

Cholesterol

Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age 70-79

Points

Nonsmoker

00 000

Smoker 85 311

Points

Nonsmoker

00 000

Smoker 97 421

Points

<160 0 0 0 0 0

160-199 4 3 2 1 1

200-239 8 6 4 2 1

240-279 11 8 5 3 2

≥280 13 10 7 4 2

Points

HDL (mg/dL) Points

≥60 -1

50-59 0

40-49 1

<40 2

HDL (mg/dL) Points

≥60 -1

50-59 0

40-49 1

<40 2

Systolic BP (mmHg) If Untreated If Treated

<120 0 0

120-129 0 1

130-139 1 2

140-159 1 2

≥160 2 3

Systolic BP (mmHg) If Untreated If Treated

<120 0 0

120-129 1 3

130-139 2 4

140-159 3 5

≥160 4 6

Men

Women

Estimate of 10-Year Risk for Men

(Framingham Point Scores)

Age Points

20-34 -9

35-39 -4

40-44 0

45-49 3

50-54 6

55-59 8

60-64 10

65-69 11

70-74 12

75-79 13

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

National Institutes of Health

National Heart, Lung, and Blood Institute

NIH Publication No. 01-3305

May 2001

Estimate of 10-Year Risk for Women

(Framingham Point Scores)

Age Points

20-34 -7

35-39 -3

40-44 0

45-49 3

50-54 6

55-59 8

60-64 10

65-69 12

70-74 14

75-79 16

10-Year risk ______% 10-Year risk ______%