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Atp 3 CHOLESTEROL GUIDELINES

This document summarizes the key guidelines from the Adult Treatment Panel III (ATP III) on cholesterol treatment and prevention. The guidelines focus on multiple risk factors like diabetes, which is considered a cardiovascular disease risk equivalent. It modifies lipid classification cut-offs and recommends a complete lipoprotein profile for screening. It provides LDL cholesterol goals and criteria for lifestyle changes or drug therapy based on a patient's risk category of having cardiovascular disease, multiple risk factors, or 0-1 risk factor. The metabolic syndrome is highlighted as a secondary target of therapy beyond LDL lowering. Case examples are given to demonstrate how the guidelines would be applied.

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Adult Treatment Panel III (ATP III) Guidelines Dr. A.P. Naveen Kumar Chief Specialist (Gen. Med.) Visakha Steel General Hospital Visakhapatnam Steel Plant National Cholesterol Education Program
2 CHO. 268 TRIG. 168 HDL 35 LDL 122
3 New Features of ATP III Focus on Multiple Risk Factors • Diabetes: CHD risk equivalent • Framingham projections of 10-year CHD risk – Identify certain patients with multiple risk factors for more intensive treatment • Multiple metabolic risk factors (metabolic syndrome) – Intensified therapeutic lifestyle changes
4 New Features of ATP III (continued) Modification of Lipid and Lipoprotein Classification • LDL cholesterol <100 mg/dL—optimal • HDL cholesterol <40 mg/dL – Categorical risk factor – Raised from <35 mg/dL • Lower triglyceride classification cut points – More attention to moderate elevations
5 New Features of ATP III (continued) New Recommendation for Screening/Detection • Complete lipoprotein profile preferred – Fasting total cholesterol, LDL, HDL, triglycerides • Secondary option – Non-fasting total cholesterol and HDL – Proceed to lipoprotein profile if TC ≥200 mg/dL or HDL <40 mg/dL
6 New Features of ATP III (continued) New strategies for Promoting Adherence In both: • Therapeutic Lifestyle Changes (TLC) • Drug therapies
7 New Features of ATP III (continued) • For patients with triglycerides ≥200 mg/dL – LDL cholesterol: primary target of therapy – Non-HDL cholesterol: secondary target of therapy Non HDL-C = total cholesterol – HDL cholesterol
ATP III Guidelines Detection and Evaluation
9 Categories of Risk Factors • Major, independent risk factors • Life-habit risk factors • Emerging risk factors
10 Life-Habit Risk Factors • Obesity (BMI ≥ 30) • Physical inactivity • Atherogenic diet
11 Emerging Risk Factors • Lipoprotein (a) • Homocysteine • Prothrombotic factors • Proinflammatory factors • Impaired fasting glucose • Subclinical atherosclerosis
12 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%
13 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.
14 Diabetes In ATP III, diabetes is regarded as a CHD risk equivalent.
15 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
16 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
17 CHD Risk Equivalents • Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease) • Diabetes • Multiple risk factors that confer a 10-year risk for CHD >20%
18 Risk Category CHD and CHD risk equivalents 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
19 ATP III Lipid and Lipoprotein Classification LDL Cholesterol (mg/dL) <100 Optimal 100–129 Near optimal/above optimal 130–159 Borderline high 160–189 High ≥190 Very high
20 ATP III Lipid and Lipoprotein Classification (continued) HDL Cholesterol (mg/dL) <40 Low ≥60 High
21 ATP III Lipid and Lipoprotein Classification (continued) Total Cholesterol (mg/dL) <200 Desirable 200–239 Borderline high ≥240 High
ATP III Guidelines Goals and Treatment Overview
23 Primary Prevention With LDL-Lowering Therapy Public Health Approach • Reduced intakes of saturated fat and cholesterol • Increased physical activity • Weight control
24 Primary Prevention Goals of Therapy • Long-term prevention (>10 years) • Short-term prevention (≤10 years)
25 Causes of Secondary Dyslipidemia • Diabetes • Hypothyroidism • Obstructive liver disease • Chronic renal failure • Drugs that raise LDL cholesterol and lower HDL cholesterol (progestins, anabolic steroids, and corticosteroids)
26 Secondary Prevention With LDL-Lowering Therapy • Benefits: reduction in total mortality, coronary mortality, major coronary events, coronary procedures, and stroke • LDL cholesterol goal: <100 mg/dL • Includes CHD risk equivalents • Consider initiation of therapy during hospitalization (if LDL ≥100 mg/dL)
27 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 optional) 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)
28 LDL Cholesterol Goal and Cutpoints for Therapeutic Lifestyle Changes (TLC) and Drug Therapy in Patients with CHD and CHD Risk Equivalents (10-Year Risk >20%) ≥130 mg/dL (100–129 mg/dL: drug optional) ≥100 mg/dL<100 mg/dL LDL Level at Which to Consider Drug Therapy LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) LDL Goal
29 LDL Cholesterol Goal and Cutpoints for Therapeutic Lifestyle Changes (TLC) and Drug Therapy in Patients with Multiple Risk Factors (10-Year Risk ≤20%) LDL Goal LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) LDL Level at Which to Consider Drug Therapy <130 mg/dL ≥130 mg/dL 10-year risk 10–20%: ≥130 mg/dL 10-year risk <10%: ≥160 mg/dL
30 LDL Cholesterol Goal and Cutpoints for Therapeutic Lifestyle Changes (TLC) and Drug Therapy in Patients with 0–1 Risk Factor ≥190 mg/dL (160–189 mg/dL: LDL-lowering drug optional) ≥160 mg/dL<160 mg/dL LDL Level at Which to Consider Drug Therapy LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC)LDL Goal
31 LDL-Lowering Therapy in Patients With CHD and CHD Risk Equivalents Baseline LDL Cholesterol: ≥130 mg/dL • Intensive lifestyle therapies • Maximal control of other risk factors • Consider starting LDL-lowering drugs simultaneously with lifestyle therapies
32 LDL-Lowering Therapy in Patients With CHD and CHD Risk Equivalents Baseline (or On-Treatment) LDL-C: 100–129 mg/dL Therapeutic Options: • LDL-lowering therapy – Initiate or intensify lifestyle therapies – Initiate or intensify LDL-lowering drugs • Treatment of metabolic syndrome – Emphasize weight reduction and increased physical activity • Drug therapy for other lipid risk factors – For high triglycerides/low HDL cholesterol – Fibrates or nicotinic acid
33 LDL-Lowering Therapy in Patients With CHD and CHD Risk Equivalents Baseline LDL-C: <100 mg/dL • Further LDL lowering not required • Therapeutic Lifestyle Changes (TLC) recommended • Consider treatment of other lipid risk factors – Elevated triglycerides – Low HDL cholesterol • Ongoing clinical trials are assessing benefit of further LDL lowering
34 LDL-Lowering Therapy in Patients With Multiple (2+) Risk Factors and 10-Year Risk ≤20% 10-Year Risk 10–20% • LDL-cholesterol goal <130 mg/dL • Aim: reduce both short-term and long-term risk • Immediate initiation of Therapeutic Lifestyle Changes (TLC) if LDL-C is ≥130 mg/dL • Consider drug therapy if LDL-C is ≥130 mg/dL after 3 months of lifestyle therapies
35 LDL-Lowering Therapy in Patients With Multiple (2+) Risk Factors and 10-Year Risk ≤20% 10-Year Risk <10% • LDL-cholesterol goal: <130 mg/dL • Therapeutic aim: reduce long-term risk • Initiate therapeutic lifestyle changes if LDL-C is ≥130 mg/dL • Consider drug therapy if LDL-C is ≥160 mg/dL after 3 months of lifestyle therapies
36 LDL-Lowering Therapy in Patients With 0–1 Risk Factor • Most persons have 10-year risk <10% • Therapeutic goal: reduce long-term risk • LDL-cholesterol goal: <160 mg/dL • Initiate therapeutic lifestyle changes if LDL-C is ≥160 mg/dL • If LDL-C is ≥190 mg/dL after 3 months of lifestyle therapies, consider drug therapy • If LDL-C is 160–189 mg/dL after 3 months of lifestyle therapies, drug therapy is optional
37 LDL-Lowering Therapy in Patients With 0–1 Risk Factor and LDL-Cholesterol 160-189 mg/dL (after lifestyle therapies) Factors Favoring Drug Therapy • Severe single risk factor • Multiple life-habit risk factors and emerging risk factors (if measured)
38 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
39 NON HTN. DM. NON SMOKING YOUNG MALE CHO. 268 TRIG. 168 HDL 35 LDL 198 ANS : LSM and TARGET LDL TO < 160 mgs
40 Htn., Smoker, Male 48 CHO. 238 TRIG. 198 HDL 30 LDL 158 Ans. : Target LDL <100 mgs
41 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.
42 DM , Male 42 yrs. Non Smoker CHO. 268 TRIG. 578 HDL 28 LDL 172 Ans. : Target LDL and TG
43 DM Young female CHO. 248 TRIG. 368 HDL 25 LDL 142 Ans . : Target LDL and HDL – Statin+Niacin
44 HTN , Smoker, Male 52 yrs. CHO. 248 TRIG. 168 HDL 30 LDL 162 Ans. : Target LDL < 130 mgs
45 Young male ,HTN ,38 Yrs. CHO. 212 TRIG 198 HDL 68 LDL 164 Ans. :HDL > 60 mgs is negative risk factor LSM target LDL <160 mgs
ATP III Guidelines Therapeutic Lifestyle Changes (TLC)
47 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
48 Therapeutic Lifestyle Changes Nutrient Composition of TLC Diet Nutrient Recommended Intake • Saturated fat Less than 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 50–60% of total calories • Fiber 20–30 grams per day • Protein Approximately 15% of total calories • Cholesterol Less than 200 mg/day • Total calories (energy) Balance energy intake and expenditure to maintain desirable body weight/ prevent weight gain
49 Efficacy of Lifestyle Strategies for Increasing HDL-C Strategy Increase in HDL-C (%) Weight reduction 5%-20% Physical activity 5%-30% Smoking cessation 5% Moderate alcohol consumption 8% Mediterranean-style diet vs. 30% fat diet* 2% *Compared with an average American diet. National Cholesterol Education Program. Circulation. 2002;106:3143-3421. Roussell MA, et al. J Clin Lipidol . 2007;1:65-73. Sacks FM, et al. Am J Med. 2002;113:13-24.
ATP III Guidelines Drug Therapy
51 Drug Therapy HMG CoA Reductase Inhibitors (Statins) • Reduce LDL-C 18–55% & TG 7–30% • Raise HDL-C 5–15% • Major side effects – Myopathy – Increased liver enzymes • Contraindications – Absolute: liver disease – Relative: use with certain drugs
52 HMG CoA Reductase Inhibitors (Statins) Statin Dose Range 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 Rosuvastatin 10 – 40 mg
53 HMG CoA Reductase Inhibitors (Statins) (continued) Demonstrated Therapeutic Benefits • Reduce major coronary events • Reduce CHD mortality • Reduce coronary procedures (PTCA/CABG) • Reduce stroke • Reduce total mortality
54 Drug Therapy Bile Acid Sequestrants • Major actions – Reduce LDL-C 15–30% – Raise HDL-C 3–5% – May increase TG • Side effects – GI distress/constipation – Decreased absorption of other drugs • Contraindications – Dysbetalipoproteinemia – Raised TG (especially >400 mg/dL)
55 Bile Acid Sequestrants Drug Dose Range Cholestyramine 4–16 g Colestipol 5–20 g Colesevelam 2.6–3.8 g
56 Bile Acid Sequestrants (continued) Demonstrated Therapeutic Benefits • Reduce major coronary events • Reduce CHD mortality
57 Drug Therapy Nicotinic Acid • Major actions – Lowers LDL-C 5–25% – Lowers TG 20–50% – Raises HDL-C 15–35% • Side effects: flushing, hyperglycemia, hyperuricemia, upper GI distress, hepatotoxicity • Contraindications: liver disease, severe gout, peptic ulcer
58 Nicotinic Acid Drug Form Dose Range Immediate release 1.5–3 g (crystalline) Extended release 1–2 g Sustained release 1–2 g
59 Nicotinic Acid (continued) Demonstrated Therapeutic Benefits • Reduces major coronary events • Possible reduction in total mortality
60 Drug Therapy Fibric Acids • Major actions – Lower LDL-C 5–20% (with normal TG) – May raise LDL-C (with high TG) – Lower TG 20–50% – Raise HDL-C 10–20% • Side effects: dyspepsia, gallstones, myopathy • Contraindications: Severe renal or hepatic disease
61 Fibric Acids Drug Dose • Gemfibrozil 600 mg BID • Fenofibrate 200 mg QD • Clofibrate 1000 mg BID
62 Fibric Acids (continued) Demonstrated Therapeutic Benefits • Reduce progression of coronary lesions • Reduce major coronary events
63 • LDL-cholesterol goal: <100 mg/dL • Most patients require drug therapy • First, achieve LDL-cholesterol goal • Second, modify other lipid and non-lipid risk factors Secondary Prevention: Drug Therapy for CHD and CHD Risk Equivalents
64 Patients Hospitalized for Coronary Events or Procedures • Measure LDL-C within 24 hours • Discharge on LDL-lowering drug if LDL-C ≥130 mg/dL • Consider LDL-lowering drug if LDL-C is 100–129 mg/dL • Start lifestyle therapies simultaneously with drug Secondary Prevention: Drug Therapy for CHD and CHD Risk Equivalents (continued)
65 Progression of Drug Therapy in Primary Prevention If LDL goal not achieved, intensify LDL-lowering therapy If LDL goal not achieved, intensify drug therapy or refer to a lipid specialist Monitor response and adherence to therapy • Start statin or bile acid sequestrant or nicotinic acid • Consider higher dose of statin or add a bile acid sequestrant or nicotinic acid 6 wks 6 wks Q 4-6 mo • If LDL goal achieved, treat other lipid risk factors Initiate LDL-lowering drug therapy
ATP III Guidelines Benefit Beyond LDL-Lowering: The Metabolic Syndrome as a Secondary Target of Therapy
67 Metabolic Syndrome Synonyms • Insulin resistance syndrome • (Metabolic) Syndrome X • Dysmetabolic syndrome • Multiple metabolic syndrome
68 Metabolic Syndrome (continued) Causes • Acquired causes – Overweight and obesity – Physical inactivity – High carbohydrate diets (>60% of energy intake) in some persons • Genetic causes
69 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)
70 Metabolic Syndrome (continued) Management of Overweight and Obesity • Overweight and obesity: lifestyle risk factors • Direct targets of intervention • Weight reduction – Enhances LDL lowering – Reduces metabolic syndrome risk factors • Clinical guidelines: Obesity Education Initiative – Techniques of weight reduction
71 Metabolic Syndrome (continued) Management of Physical Inactivity • Physical inactivity: lifestyle risk factor • Direct target of intervention • Increased physical activity – Reduces metabolic syndrome risk factors – Improves cardiovascular function • Clinical guidelines: U.S. Surgeon General’s Report on Physical Activity
ATP III Guidelines Specific Dyslipidemias
73 Specific Dyslipidemias: Very High LDL Cholesterol (≥190 mg/dL) Causes and Diagnosis • Genetic disorders – Monogenic familial hypercholesterolemia – Familial defective apolipoprotein B-100 – Polygenic hypercholesterolemia • Family testing to detect affected relatives
74 Specific Dyslipidemias: Very High LDL Cholesterol (≥190 mg/dL) (continued) Management • LDL-lowering drugs – Statins (higher doses) – Statins + bile acid sequestrants – Statins + bile acid sequestrants + nicotinic acid
75 Specific Dyslipidemias: Elevated Triglycerides Classification of Serum Triglycerides • Normal <150 mg/dL • Borderline high 150–199 mg/dL • High 200–499 mg/dL • Very high ≥500 mg/dL
76 Specific Dyslipidemias: Elevated Triglycerides (≥150 mg/dL) Causes of Elevated Triglycerides • Obesity and overweight • Physical inactivity • Cigarette smoking • Excess alcohol intake
77 Specific Dyslipidemias: Elevated Triglycerides Causes of Elevated Triglycerides (continued) • High carbohydrate diets (>60% of energy intake) • Several diseases (type 2 diabetes, chronic renal failure, nephrotic syndrome) • Certain drugs (corticosteroids, estrogens, retinoids, higher doses of beta-blockers) • Various genetic dyslipidemias
78 Specific Dyslipidemias: Elevated Triglycerides (continued) Non-HDL Cholesterol: Secondary Target • Non-HDL cholesterol = VLDL + LDL cholesterol = (Total Cholesterol – HDL cholesterol) • VLDL cholesterol: denotes atherogenic remnant lipoproteins • Non-HDL cholesterol: secondary target of therapy when serum triglycerides are ≥200 mg/dL (esp. 200–499 mg/dL) • Non-HDL cholesterol goal: LDL-cholesterol goal + 30 mg/dL
79 Comparison of LDL Cholesterol and Non-HDL Cholesterol Goals for Three Risk Categories LDL-C Goal (mg/dL)Risk Category Non-HDL-C Goal (mg/dL) <100 CHD and CHD Risk Equivalent (10-year risk for CHD >20% <130 <130 Multiple (2+) Risk Factors and 10-year risk <20% <160 <1600–1 Risk Factor <190
80 Specific Dyslipidemias: Elevated Triglycerides Non-HDL Cholesterol: Secondary Target • Primary target of therapy: LDL cholesterol • Achieve LDL goal before treating non-HDL cholesterol • Therapeutic approaches to elevated non-HDL cholesterol – Intensify therapeutic lifestyle changes – Intensify LDL-lowering drug therapy – Nicotinic acid or fibrate therapy to lower VLDL
81 Specific Dyslipidemias: Elevated Triglycerides Management of Very High Triglycerides (≥500 mg/dL) • Goal of therapy: prevent acute pancreatitis • Very low fat diets (≤15% of caloric intake) • Triglyceride-lowering drug usually required (fibrate or nicotinic acid) • Reduce triglycerides before LDL lowering
82 DM,SMOKER,POST PTCA,MALE 66 YRS. CHO. 228 TRIG. 338 HDL 30 LDL 122 ANS: TARGET LDL
83 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.
84 NON HTN. ,DM, NON SMOKER CHO. 208 TRIG. 555 HDL 35 LDL 0 ANS : FIBRATE
85 HTN. , DM, MALE 34 CHO. 196 TRIG. 248 HDL 35 LDL 96 • ANS : TARGET NON HDL CHOLESTEROL
86 Specific Dyslipidemias: Low HDL Cholesterol Causes of Low HDL Cholesterol (<40 mg/dL) • Elevated triglycerides • Overweight and obesity • Physical inactivity • Type 2 diabetes • Cigarette smoking • Very high carbohydrate intakes (>60% energy) • Certain drugs (beta-blockers, anabolic steroids, progestational agents)
87 Specific Dyslipidemias: Low HDL Cholesterol Management of Low HDL Cholesterol • LDL cholesterol is primary target of therapy • Weight reduction and increased physical activity (if the metabolic syndrome is present) • Non-HDL cholesterol is secondary target of therapy (if triglycerides ≥200 mg/dL) • Consider nicotinic acid or fibrates (for patients with CHD or CHD risk equivalents)
88 • Lipoprotein pattern: atherogenic dyslipidemia (high TG, low HDL, small LDL particles) • LDL-cholesterol goal: <100 mg/dL • Baseline LDL-cholesterol ≥130 mg/dL – Most patients require LDL-lowering drugs • Baseline LDL-cholesterol 100–129 mg/dL – Consider therapeutic options • Baseline triglycerides: ≥200 mg/dL – Non-HDL cholesterol: secondary target of therapy Specific Dyslipidemias: Diabetic Dyslipidemia
ATP III Guidelines Population Groups
90 Special Considerations for Different Population Groups Younger Adults • Men 20–35 years; women 20–45 years • Coronary atherosclerosis accelerated by CHD risk factors • Routine cholesterol screening recommended starting at age 20 • Hypercholesterolemic patients may need LDL- lowering drugs
91 Special Considerations for Different Population Groups (continued) Older Adults • Men ≥65 years and women ≥75 years • High LDL and low HDL still predict CHD • Benefits of LDL-lowering therapy extend to older adults • Clinical judgment required for appropriate use of LDL-lowering drugs
92 Special Considerations for Different Population Groups (continued) Women (Ages 45–75 years) • CHD in women delayed by 10–15 years (compared to men) • Most CHD in women occurs after age 65 • For secondary prevention in post-menopausal women – Benefits of hormone replacement therapy doubtful – Benefits of statin therapy documented in clinical trials
93 Special Considerations for Different Population Groups (continued) Middle-Aged Men (35–65 years) • CHD risk in men > women • High prevalence of CHD risk factors • Men prone to abdominal obesity and metabolic syndrome • CHD incidence high in middle-aged men • Strong clinical trial evidence for benefit of LDL- lowering therapy
94 Special Considerations for Different Population Groups (continued) Racial and Ethnic Groups • Absolute risk for CHD may vary in different racial and ethnic groups • Relative risk from risk factors is similar for all population groups • ATP III guidelines apply to: – African Americans – Hispanics – Native Americans – Asian and Pacific Islanders – South Asians
95 THANK YOU

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In this document
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Introduction to Adult Treatment Panel III guidelines by Dr. A.P. Naveen Kumar focusing on cholesterol management.

Key cholesterol values are presented: Total Cholesterol 268, Triglycerides 168, HDL 35, LDL 122.

Focus on multiple risk factors, defining diabetes as a CHD risk equivalent, and updating lipid classifications.

Risk factors are categorized into major, life-habit, and emerging groups, guiding the 10-year risk assessment.

Identification of risk factors that modify LDL goals, emphasizing the severity of diabetes and its relation to CHD.

Classifications of cholesterol: optimal LDL under 100 mg/dL, HDL less than 40 mg/dL as a risk factor.

Strategies for primary and secondary prevention of CHD focusing on LDL-lowering therapy and lifestyle changes.

Detailed therapeutic goals by risk category and the importance of lifestyle changes alongside drug therapy.

Different drug therapies outlined include Statins, Bile Acid Sequestrants, Nicotinic Acid, and Fibric Acids.

Importance of drug therapy for secondary prevention of coronary events and adjusting protocols based on LDL outcomes.Overview of metabolic syndrome, its causes, and recommendations for lifestyle modifications to mitigate risk.

Focus on managing dyslipidemias like very high LDL cholesterol and elevated triglycerides, including treatment goals.

Special considerations for different population groups regarding cholesterol management and risk factors.

Closing remarks thanking the audience, summarizing the importance of ATP III guidelines in patient care.

Atp 3 CHOLESTEROL GUIDELINES

  • 1.
    Adult Treatment PanelIII (ATP III) Guidelines Dr. A.P. Naveen Kumar Chief Specialist (Gen. Med.) Visakha Steel General Hospital Visakhapatnam Steel Plant National Cholesterol Education Program
  • 2.
  • 3.
    3 New Features ofATP III Focus on Multiple Risk Factors • Diabetes: CHD risk equivalent • Framingham projections of 10-year CHD risk – Identify certain patients with multiple risk factors for more intensive treatment • Multiple metabolic risk factors (metabolic syndrome) – Intensified therapeutic lifestyle changes
  • 4.
    4 New Features ofATP III (continued) Modification of Lipid and Lipoprotein Classification • LDL cholesterol <100 mg/dL—optimal • HDL cholesterol <40 mg/dL – Categorical risk factor – Raised from <35 mg/dL • Lower triglyceride classification cut points – More attention to moderate elevations
  • 5.
    5 New Features ofATP III (continued) New Recommendation for Screening/Detection • Complete lipoprotein profile preferred – Fasting total cholesterol, LDL, HDL, triglycerides • Secondary option – Non-fasting total cholesterol and HDL – Proceed to lipoprotein profile if TC ≥200 mg/dL or HDL <40 mg/dL
  • 6.
    6 New Features ofATP III (continued) New strategies for Promoting Adherence In both: • Therapeutic Lifestyle Changes (TLC) • Drug therapies
  • 7.
    7 New Features ofATP III (continued) • For patients with triglycerides ≥200 mg/dL – LDL cholesterol: primary target of therapy – Non-HDL cholesterol: secondary target of therapy Non HDL-C = total cholesterol – HDL cholesterol
  • 8.
  • 9.
    9 Categories of RiskFactors • Major, independent risk factors • Life-habit risk factors • Emerging risk factors
  • 10.
    10 Life-Habit Risk Factors •Obesity (BMI ≥ 30) • Physical inactivity • Atherogenic diet
  • 11.
    11 Emerging Risk Factors •Lipoprotein (a) • Homocysteine • Prothrombotic factors • Proinflammatory factors • Impaired fasting glucose • Subclinical atherosclerosis
  • 12.
    12 Risk Assessment Count majorrisk 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%
  • 13.
    13 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.
  • 14.
    14 Diabetes In ATP III,diabetes is regarded as a CHD risk equivalent.
  • 15.
    15 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
  • 16.
    16 Diabetes as aCHD Risk Equivalent • 10-year risk for CHD ≅ 20% • High mortality with established CHD – High mortality with acute MI – High mortality post acute MI
  • 17.
    17 CHD Risk Equivalents •Other clinical forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and symptomatic carotid artery disease) • Diabetes • Multiple risk factors that confer a 10-year risk for CHD >20%
  • 18.
    18 Risk Category CHD andCHD risk equivalents 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
  • 19.
    19 ATP III Lipidand Lipoprotein Classification LDL Cholesterol (mg/dL) <100 Optimal 100–129 Near optimal/above optimal 130–159 Borderline high 160–189 High ≥190 Very high
  • 20.
    20 ATP III Lipidand Lipoprotein Classification (continued) HDL Cholesterol (mg/dL) <40 Low ≥60 High
  • 21.
    21 ATP III Lipidand Lipoprotein Classification (continued) Total Cholesterol (mg/dL) <200 Desirable 200–239 Borderline high ≥240 High
  • 22.
    ATP III Guidelines Goalsand Treatment Overview
  • 23.
    23 Primary Prevention With LDL-LoweringTherapy Public Health Approach • Reduced intakes of saturated fat and cholesterol • Increased physical activity • Weight control
  • 24.
    24 Primary Prevention Goals ofTherapy • Long-term prevention (>10 years) • Short-term prevention (≤10 years)
  • 25.
    25 Causes of SecondaryDyslipidemia • Diabetes • Hypothyroidism • Obstructive liver disease • Chronic renal failure • Drugs that raise LDL cholesterol and lower HDL cholesterol (progestins, anabolic steroids, and corticosteroids)
  • 26.
    26 Secondary Prevention With LDL-LoweringTherapy • Benefits: reduction in total mortality, coronary mortality, major coronary events, coronary procedures, and stroke • LDL cholesterol goal: <100 mg/dL • Includes CHD risk equivalents • Consider initiation of therapy during hospitalization (if LDL ≥100 mg/dL)
  • 27.
    27 LDL Cholesterol Goalsand 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 optional) 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)
  • 28.
    28 LDL Cholesterol Goaland Cutpoints for Therapeutic Lifestyle Changes (TLC) and Drug Therapy in Patients with CHD and CHD Risk Equivalents (10-Year Risk >20%) ≥130 mg/dL (100–129 mg/dL: drug optional) ≥100 mg/dL<100 mg/dL LDL Level at Which to Consider Drug Therapy LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) LDL Goal
  • 29.
    29 LDL Cholesterol Goaland Cutpoints for Therapeutic Lifestyle Changes (TLC) and Drug Therapy in Patients with Multiple Risk Factors (10-Year Risk ≤20%) LDL Goal LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC) LDL Level at Which to Consider Drug Therapy <130 mg/dL ≥130 mg/dL 10-year risk 10–20%: ≥130 mg/dL 10-year risk <10%: ≥160 mg/dL
  • 30.
    30 LDL Cholesterol Goaland Cutpoints for Therapeutic Lifestyle Changes (TLC) and Drug Therapy in Patients with 0–1 Risk Factor ≥190 mg/dL (160–189 mg/dL: LDL-lowering drug optional) ≥160 mg/dL<160 mg/dL LDL Level at Which to Consider Drug Therapy LDL Level at Which to Initiate Therapeutic Lifestyle Changes (TLC)LDL Goal
  • 31.
    31 LDL-Lowering Therapy inPatients With CHD and CHD Risk Equivalents Baseline LDL Cholesterol: ≥130 mg/dL • Intensive lifestyle therapies • Maximal control of other risk factors • Consider starting LDL-lowering drugs simultaneously with lifestyle therapies
  • 32.
    32 LDL-Lowering Therapy inPatients With CHD and CHD Risk Equivalents Baseline (or On-Treatment) LDL-C: 100–129 mg/dL Therapeutic Options: • LDL-lowering therapy – Initiate or intensify lifestyle therapies – Initiate or intensify LDL-lowering drugs • Treatment of metabolic syndrome – Emphasize weight reduction and increased physical activity • Drug therapy for other lipid risk factors – For high triglycerides/low HDL cholesterol – Fibrates or nicotinic acid
  • 33.
    33 LDL-Lowering Therapy inPatients With CHD and CHD Risk Equivalents Baseline LDL-C: <100 mg/dL • Further LDL lowering not required • Therapeutic Lifestyle Changes (TLC) recommended • Consider treatment of other lipid risk factors – Elevated triglycerides – Low HDL cholesterol • Ongoing clinical trials are assessing benefit of further LDL lowering
  • 34.
    34 LDL-Lowering Therapy inPatients With Multiple (2+) Risk Factors and 10-Year Risk ≤20% 10-Year Risk 10–20% • LDL-cholesterol goal <130 mg/dL • Aim: reduce both short-term and long-term risk • Immediate initiation of Therapeutic Lifestyle Changes (TLC) if LDL-C is ≥130 mg/dL • Consider drug therapy if LDL-C is ≥130 mg/dL after 3 months of lifestyle therapies
  • 35.
    35 LDL-Lowering Therapy inPatients With Multiple (2+) Risk Factors and 10-Year Risk ≤20% 10-Year Risk <10% • LDL-cholesterol goal: <130 mg/dL • Therapeutic aim: reduce long-term risk • Initiate therapeutic lifestyle changes if LDL-C is ≥130 mg/dL • Consider drug therapy if LDL-C is ≥160 mg/dL after 3 months of lifestyle therapies
  • 36.
    36 LDL-Lowering Therapy inPatients With 0–1 Risk Factor • Most persons have 10-year risk <10% • Therapeutic goal: reduce long-term risk • LDL-cholesterol goal: <160 mg/dL • Initiate therapeutic lifestyle changes if LDL-C is ≥160 mg/dL • If LDL-C is ≥190 mg/dL after 3 months of lifestyle therapies, consider drug therapy • If LDL-C is 160–189 mg/dL after 3 months of lifestyle therapies, drug therapy is optional
  • 37.
    37 LDL-Lowering Therapy inPatients With 0–1 Risk Factor and LDL-Cholesterol 160-189 mg/dL (after lifestyle therapies) Factors Favoring Drug Therapy • Severe single risk factor • Multiple life-habit risk factors and emerging risk factors (if measured)
  • 38.
    38 Benefit Beyond LDLLowering: 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
  • 39.
    39 NON HTN. DM.NON SMOKING YOUNG MALE CHO. 268 TRIG. 168 HDL 35 LDL 198 ANS : LSM and TARGET LDL TO < 160 mgs
  • 40.
    40 Htn., Smoker, Male48 CHO. 238 TRIG. 198 HDL 30 LDL 158 Ans. : Target LDL <100 mgs
  • 41.
    41 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.
  • 42.
    42 DM , Male42 yrs. Non Smoker CHO. 268 TRIG. 578 HDL 28 LDL 172 Ans. : Target LDL and TG
  • 43.
    43 DM Young female CHO.248 TRIG. 368 HDL 25 LDL 142 Ans . : Target LDL and HDL – Statin+Niacin
  • 44.
    44 HTN , Smoker,Male 52 yrs. CHO. 248 TRIG. 168 HDL 30 LDL 162 Ans. : Target LDL < 130 mgs
  • 45.
    45 Young male ,HTN,38 Yrs. CHO. 212 TRIG 198 HDL 68 LDL 164 Ans. :HDL > 60 mgs is negative risk factor LSM target LDL <160 mgs
  • 46.
    ATP III Guidelines TherapeuticLifestyle Changes (TLC)
  • 47.
    47 Therapeutic Lifestyle Changesin 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
  • 48.
    48 Therapeutic Lifestyle Changes NutrientComposition of TLC Diet Nutrient Recommended Intake • Saturated fat Less than 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 50–60% of total calories • Fiber 20–30 grams per day • Protein Approximately 15% of total calories • Cholesterol Less than 200 mg/day • Total calories (energy) Balance energy intake and expenditure to maintain desirable body weight/ prevent weight gain
  • 49.
    49 Efficacy of LifestyleStrategies for Increasing HDL-C Strategy Increase in HDL-C (%) Weight reduction 5%-20% Physical activity 5%-30% Smoking cessation 5% Moderate alcohol consumption 8% Mediterranean-style diet vs. 30% fat diet* 2% *Compared with an average American diet. National Cholesterol Education Program. Circulation. 2002;106:3143-3421. Roussell MA, et al. J Clin Lipidol . 2007;1:65-73. Sacks FM, et al. Am J Med. 2002;113:13-24.
  • 50.
  • 51.
    51 Drug Therapy HMG CoAReductase Inhibitors (Statins) • Reduce LDL-C 18–55% & TG 7–30% • Raise HDL-C 5–15% • Major side effects – Myopathy – Increased liver enzymes • Contraindications – Absolute: liver disease – Relative: use with certain drugs
  • 52.
    52 HMG CoA Reductase Inhibitors(Statins) Statin Dose Range 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 Rosuvastatin 10 – 40 mg
  • 53.
    53 HMG CoA Reductase Inhibitors(Statins) (continued) Demonstrated Therapeutic Benefits • Reduce major coronary events • Reduce CHD mortality • Reduce coronary procedures (PTCA/CABG) • Reduce stroke • Reduce total mortality
  • 54.
    54 Drug Therapy Bile AcidSequestrants • Major actions – Reduce LDL-C 15–30% – Raise HDL-C 3–5% – May increase TG • Side effects – GI distress/constipation – Decreased absorption of other drugs • Contraindications – Dysbetalipoproteinemia – Raised TG (especially >400 mg/dL)
  • 55.
    55 Bile Acid Sequestrants DrugDose Range Cholestyramine 4–16 g Colestipol 5–20 g Colesevelam 2.6–3.8 g
  • 56.
    56 Bile Acid Sequestrants(continued) Demonstrated Therapeutic Benefits • Reduce major coronary events • Reduce CHD mortality
  • 57.
    57 Drug Therapy Nicotinic Acid •Major actions – Lowers LDL-C 5–25% – Lowers TG 20–50% – Raises HDL-C 15–35% • Side effects: flushing, hyperglycemia, hyperuricemia, upper GI distress, hepatotoxicity • Contraindications: liver disease, severe gout, peptic ulcer
  • 58.
    58 Nicotinic Acid Drug FormDose Range Immediate release 1.5–3 g (crystalline) Extended release 1–2 g Sustained release 1–2 g
  • 59.
    59 Nicotinic Acid (continued) DemonstratedTherapeutic Benefits • Reduces major coronary events • Possible reduction in total mortality
  • 60.
    60 Drug Therapy Fibric Acids •Major actions – Lower LDL-C 5–20% (with normal TG) – May raise LDL-C (with high TG) – Lower TG 20–50% – Raise HDL-C 10–20% • Side effects: dyspepsia, gallstones, myopathy • Contraindications: Severe renal or hepatic disease
  • 61.
    61 Fibric Acids Drug Dose •Gemfibrozil 600 mg BID • Fenofibrate 200 mg QD • Clofibrate 1000 mg BID
  • 62.
    62 Fibric Acids (continued) DemonstratedTherapeutic Benefits • Reduce progression of coronary lesions • Reduce major coronary events
  • 63.
    63 • LDL-cholesterol goal:<100 mg/dL • Most patients require drug therapy • First, achieve LDL-cholesterol goal • Second, modify other lipid and non-lipid risk factors Secondary Prevention: Drug Therapy for CHD and CHD Risk Equivalents
  • 64.
    64 Patients Hospitalized forCoronary Events or Procedures • Measure LDL-C within 24 hours • Discharge on LDL-lowering drug if LDL-C ≥130 mg/dL • Consider LDL-lowering drug if LDL-C is 100–129 mg/dL • Start lifestyle therapies simultaneously with drug Secondary Prevention: Drug Therapy for CHD and CHD Risk Equivalents (continued)
  • 65.
    65 Progression of DrugTherapy in Primary Prevention If LDL goal not achieved, intensify LDL-lowering therapy If LDL goal not achieved, intensify drug therapy or refer to a lipid specialist Monitor response and adherence to therapy • Start statin or bile acid sequestrant or nicotinic acid • Consider higher dose of statin or add a bile acid sequestrant or nicotinic acid 6 wks 6 wks Q 4-6 mo • If LDL goal achieved, treat other lipid risk factors Initiate LDL-lowering drug therapy
  • 66.
    ATP III Guidelines BenefitBeyond LDL-Lowering: The Metabolic Syndrome as a Secondary Target of Therapy
  • 67.
    67 Metabolic Syndrome Synonyms • Insulinresistance syndrome • (Metabolic) Syndrome X • Dysmetabolic syndrome • Multiple metabolic syndrome
  • 68.
    68 Metabolic Syndrome (continued) Causes •Acquired causes – Overweight and obesity – Physical inactivity – High carbohydrate diets (>60% of energy intake) in some persons • Genetic causes
  • 69.
    69 Metabolic Syndrome (continued) TherapeuticObjectives • 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)
  • 70.
    70 Metabolic Syndrome (continued) Managementof Overweight and Obesity • Overweight and obesity: lifestyle risk factors • Direct targets of intervention • Weight reduction – Enhances LDL lowering – Reduces metabolic syndrome risk factors • Clinical guidelines: Obesity Education Initiative – Techniques of weight reduction
  • 71.
    71 Metabolic Syndrome (continued) Managementof Physical Inactivity • Physical inactivity: lifestyle risk factor • Direct target of intervention • Increased physical activity – Reduces metabolic syndrome risk factors – Improves cardiovascular function • Clinical guidelines: U.S. Surgeon General’s Report on Physical Activity
  • 72.
  • 73.
    73 Specific Dyslipidemias: Very HighLDL Cholesterol (≥190 mg/dL) Causes and Diagnosis • Genetic disorders – Monogenic familial hypercholesterolemia – Familial defective apolipoprotein B-100 – Polygenic hypercholesterolemia • Family testing to detect affected relatives
  • 74.
    74 Specific Dyslipidemias: Very HighLDL Cholesterol (≥190 mg/dL) (continued) Management • LDL-lowering drugs – Statins (higher doses) – Statins + bile acid sequestrants – Statins + bile acid sequestrants + nicotinic acid
  • 75.
    75 Specific Dyslipidemias: Elevated Triglycerides Classificationof Serum Triglycerides • Normal <150 mg/dL • Borderline high 150–199 mg/dL • High 200–499 mg/dL • Very high ≥500 mg/dL
  • 76.
    76 Specific Dyslipidemias: Elevated Triglycerides(≥150 mg/dL) Causes of Elevated Triglycerides • Obesity and overweight • Physical inactivity • Cigarette smoking • Excess alcohol intake
  • 77.
    77 Specific Dyslipidemias: Elevated Triglycerides Causesof Elevated Triglycerides (continued) • High carbohydrate diets (>60% of energy intake) • Several diseases (type 2 diabetes, chronic renal failure, nephrotic syndrome) • Certain drugs (corticosteroids, estrogens, retinoids, higher doses of beta-blockers) • Various genetic dyslipidemias
  • 78.
    78 Specific Dyslipidemias: Elevated Triglycerides(continued) Non-HDL Cholesterol: Secondary Target • Non-HDL cholesterol = VLDL + LDL cholesterol = (Total Cholesterol – HDL cholesterol) • VLDL cholesterol: denotes atherogenic remnant lipoproteins • Non-HDL cholesterol: secondary target of therapy when serum triglycerides are ≥200 mg/dL (esp. 200–499 mg/dL) • Non-HDL cholesterol goal: LDL-cholesterol goal + 30 mg/dL
  • 79.
    79 Comparison of LDLCholesterol and Non-HDL Cholesterol Goals for Three Risk Categories LDL-C Goal (mg/dL)Risk Category Non-HDL-C Goal (mg/dL) <100 CHD and CHD Risk Equivalent (10-year risk for CHD >20% <130 <130 Multiple (2+) Risk Factors and 10-year risk <20% <160 <1600–1 Risk Factor <190
  • 80.
    80 Specific Dyslipidemias: Elevated Triglycerides Non-HDLCholesterol: Secondary Target • Primary target of therapy: LDL cholesterol • Achieve LDL goal before treating non-HDL cholesterol • Therapeutic approaches to elevated non-HDL cholesterol – Intensify therapeutic lifestyle changes – Intensify LDL-lowering drug therapy – Nicotinic acid or fibrate therapy to lower VLDL
  • 81.
    81 Specific Dyslipidemias: Elevated Triglycerides Managementof Very High Triglycerides (≥500 mg/dL) • Goal of therapy: prevent acute pancreatitis • Very low fat diets (≤15% of caloric intake) • Triglyceride-lowering drug usually required (fibrate or nicotinic acid) • Reduce triglycerides before LDL lowering
  • 82.
    82 DM,SMOKER,POST PTCA,MALE 66YRS. CHO. 228 TRIG. 338 HDL 30 LDL 122 ANS: TARGET LDL
  • 83.
    83 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.
  • 84.
    84 NON HTN. ,DM,NON SMOKER CHO. 208 TRIG. 555 HDL 35 LDL 0 ANS : FIBRATE
  • 85.
    85 HTN. , DM,MALE 34 CHO. 196 TRIG. 248 HDL 35 LDL 96 • ANS : TARGET NON HDL CHOLESTEROL
  • 86.
    86 Specific Dyslipidemias: Low HDLCholesterol Causes of Low HDL Cholesterol (<40 mg/dL) • Elevated triglycerides • Overweight and obesity • Physical inactivity • Type 2 diabetes • Cigarette smoking • Very high carbohydrate intakes (>60% energy) • Certain drugs (beta-blockers, anabolic steroids, progestational agents)
  • 87.
    87 Specific Dyslipidemias: Low HDLCholesterol Management of Low HDL Cholesterol • LDL cholesterol is primary target of therapy • Weight reduction and increased physical activity (if the metabolic syndrome is present) • Non-HDL cholesterol is secondary target of therapy (if triglycerides ≥200 mg/dL) • Consider nicotinic acid or fibrates (for patients with CHD or CHD risk equivalents)
  • 88.
    88 • Lipoprotein pattern:atherogenic dyslipidemia (high TG, low HDL, small LDL particles) • LDL-cholesterol goal: <100 mg/dL • Baseline LDL-cholesterol ≥130 mg/dL – Most patients require LDL-lowering drugs • Baseline LDL-cholesterol 100–129 mg/dL – Consider therapeutic options • Baseline triglycerides: ≥200 mg/dL – Non-HDL cholesterol: secondary target of therapy Specific Dyslipidemias: Diabetic Dyslipidemia
  • 89.
  • 90.
    90 Special Considerations for DifferentPopulation Groups Younger Adults • Men 20–35 years; women 20–45 years • Coronary atherosclerosis accelerated by CHD risk factors • Routine cholesterol screening recommended starting at age 20 • Hypercholesterolemic patients may need LDL- lowering drugs
  • 91.
    91 Special Considerations for DifferentPopulation Groups (continued) Older Adults • Men ≥65 years and women ≥75 years • High LDL and low HDL still predict CHD • Benefits of LDL-lowering therapy extend to older adults • Clinical judgment required for appropriate use of LDL-lowering drugs
  • 92.
    92 Special Considerations for DifferentPopulation Groups (continued) Women (Ages 45–75 years) • CHD in women delayed by 10–15 years (compared to men) • Most CHD in women occurs after age 65 • For secondary prevention in post-menopausal women – Benefits of hormone replacement therapy doubtful – Benefits of statin therapy documented in clinical trials
  • 93.
    93 Special Considerations for DifferentPopulation Groups (continued) Middle-Aged Men (35–65 years) • CHD risk in men > women • High prevalence of CHD risk factors • Men prone to abdominal obesity and metabolic syndrome • CHD incidence high in middle-aged men • Strong clinical trial evidence for benefit of LDL- lowering therapy
  • 94.
    94 Special Considerations for DifferentPopulation Groups (continued) Racial and Ethnic Groups • Absolute risk for CHD may vary in different racial and ethnic groups • Relative risk from risk factors is similar for all population groups • ATP III guidelines apply to: – African Americans – Hispanics – Native Americans – Asian and Pacific Islanders – South Asians
  • 95.

Editor's Notes