Assessment
Additional risk factors
Cardiovascular risk factors in addition to LDL-C include the presence or absence of CHD, other clinical forms of atherosclerosis, and the major risk factors other than LDL-C shown in Table 2.1 LDL-C is not counted among the risk factors in Table 2 because the purpose of assessing those risk factors is to modify cholesterol-lowering therapy based on an individual patient’s risk profile.
Table 2. Major Risk Factors That Modify Cholesterol-Lowering Recommendations*
- Smoking
- Hypertension (BP ≥140/90 mmHg or on antihypertensive medication)
- Low HDL-C (<40 mg/dL /1.0 mmol/L)*
- 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 / 1.6 mmol/L counts as a “negative” risk factor; its presence removes one risk factor from the total count. ** In ATP III, diabetes is regarded as a CHD risk equivalent.
Risk categories:
Based on these additional risk factors, ATP III identifies three categories of risk that modify their recommendations for cholesterol-lowering therapy in order to optimise patient outcomes. These three categories of risk and their corresponding cholesterol-lowering recommendation are defined in Table 3.1
| Risk Category | LDL-C Recommendation mg/dL (mmol/L) |
|---|---|
| CHD and CHD risk equivalents | <100 (<2.6) |
| Multiple (2+) risk factors† | <130 (<3.4) |
| Zero to one risk factor | <160 (<4.1) |
Risk factors that modify the LDL goal are listed in Table 3
High risk patients:
The category of highest risk consists of CHD and CHD risk equivalents. The latter carry a risk for major coronary events equal to that of established CHD, i.e. >20% per 10 years (more than 20 of 100 such individuals will develop CHD or have a recurrent CHD event within 10 years). CHD risk equivalents are:
- 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%
Diabetes counts as a CHD risk equivalent because it confers a high risk of new CHD within 10 years, in part because of its frequent association with multiple risk factors. Additionally, because individuals with diabetes who experience a myocardial infarction have an unusually high death rate either immediately or in the long term, a more intensive cholesterol-lowering strategy is recommended. Individuals with CHD or CHD risk equivalents are at the highest cardiovascular risk – intensive cholesterol-lowering therapy is recommended for these patients to reach the lowest LDL-C level (<100 mg/dL / 2.6 mmol/L) for the greatest risk reduction.
Moderate risk patients:
The second category consists of individuals with multiple (2+) risk factors with a 10-year risk for CHD ≤20%. Risk for these patients is estimated from the Framingham risk scores. The major risk factors listed in Table 3 are used to define the presence of multiple risk factors that modify cholesterol-lowering recommendations. The LDL-C level recommended for patients with multiple (2+) risk factors is <130 mg/dL (3.4 mmol/L).
The third category consists of individuals with zero to one risk factor. With few exceptions, patients in this category have a 10-year risk <10%, and their recommended LDL-C level is <160 mg/dL (4.1 mmol/L).
Reference:
1. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III): Executive Summary. May 2001:NIH Publication No. 01-3670. This guideline document, published by the National Heart, Lung, and Blood Institute (NHLBI), as a part of the NIH and the U.S. Department of Health and Human Services, is available at: http:/anti-infectives/Paris-Event/Live-Webcast.cfmwww.nhlbi.nih.gov/guidelines/cholesterol/index.htm.