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Cholesterol Guidelines

The National Cholesterol Education Program's (NCEP's) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults creates updated clinical guidelines for testing and management of cholesterol. NCEP periodically updates existing recommendations based on new research. The third version, Adult Treatment Panel III or ATPIII, was published in 2001. In 2004, updates were added based on several clinical trials of statin therapy.

The fact is, elevated low-density lipoprotein (LDL), the bad cholesterol, is a major cause of heart disease. LDL causes the build-up of fatty deposits within your arteries, reducing or blocking the flow of blood and oxygen your heart needs. This can lead to chest pain and heart attack. (Atherosclerosis, the medical term for "hardening of the arteries," is not limited to heart arteries, though. It also occurs in arteries elsewhere in your body, causing problems such as stroke, kidney failure and poor circulation.). In addition, studies show that lowering LDL cholesterol reduces risk for coronary heart disease. For this reason, ATPIII continues to focus goals of initiating treatment based on LDL.

It is extremely important for everyone -- men and women of every age, with or without known heart disease — to have a low LDL cholesterol level. The optimal guideline level of LDL cholesterol is less than 100 mg/dl. Research from the Cleveland Clinic (REVERSAL study) compared two cholesterol lowering drugs (pravastatin and atorvastatin) and found that lower levels of LDL, as low as 60 mg/dl had better outcomes. A second study called PROVE-IT also found that the lower the LDL cholesterol the better - the PROVE-IT study results stated - "These findings indicate that patients who have recently had an acute coronary syndrome benefit from early and continued lowering of LDL cholesterol to levels substantially below current target levels." TNT, Treating to New Targets also found that "intensive Atorvastatin therapy to achieve LDL cholesterol concentrations well below recommended target levels provides an incremental clinical benefit in patients with stable coronary artery disease." These studies have impacted LDL goals and have provided now options as to when to initiate drug therapy — as seen in the new updates.

Additional research has shown that statins, drugs used to treat high LDL cholesterol appear to also protect the heart in other ways. These drugs also reduce the progression of plaque buildup in the coronary arteries by reducing C-reactive protein, a measure of inflammation in the arteries. Therefore, it seems the lower the LDL cholesterol the better, and how you get there may be important as well.

Measure your LDL and other blood lipids

Everyone age 20 and older should have their cholesterol checked at least every five years through a blood test. The guidelines recommend you have a complete "lipoprotein profile" that measures total cholesterol, LDL cholesterol, high-density lipoprotein (HDL, the good cholesterol that may help prevent heart disease), and triglycerides, another type of fat in the blood stream. The test should be performed after fasting.

Low density lipoprotein (LDL cholesterol) goal values:

  • Less than 70 mg/dL for those with heart or blood vessel disease and for other patients at very high risk of heart disease (those with metabolic syndrome)
  • Less than 100 mg/dL for high risk patients (for example: some patients who have diabetes or multiple heart disease risk factors)
  • Less than 130 mg/dL otherwise

Total cholesterol (TC) goal values:

  • 75-169 mg/dL for those age 20 and younger
  • 100-199 mg/dL for those over age 21

High density lipoprotein (HDL) goal value:

  • Greater than 45 mg/dl (the higher the better)

Triglyceride (TG) goal value:

  • Less than 150 mg/dl

Determine your other risk factors for heart disease

If you have already diagnosed coronary heart disease, atherosclerosis, or diabetes, the guidelines would place you into the high risk category, even if you have no symptoms of heart disease.

In addition to high LDL, atherosclerosis or diabetes, other important risk factors for heart disease are:

  • Cigarette smoking
  • High blood pressure (140/90 mm Hg and above or on blood pressure medication)
  • low HDL cholesterol
  • family history of early coronary heart disease
  • age (for men, age 45 or older; for women, age 55 or older)

For people who do not have coronary disease, but who have two or more risk factors, doctors may use a risk-factor chart* plus your LDL level to calculate your 10-year risk of developing disease and determine whether intensive cholesterol lowering is warranted.

With this risk-factor information, your doctor will place you in one of four categories of risk for heart disease. The higher your risk, the lower your LDL cholesterol goal will be:

If You Have You Are in Category LDL goal
Heart disease, diabetes, other forms of atherosclerosis and multiple risk factors listed above (and risk score* greater than 20%) I. Highest Risk LDL level of less than 100 mg/dl with a therapeutic option of treating to under 70 mg/dL. For very high-risk patients whose LDL levels are already below 100 mg/dL, there is also an option to use drug therapy to reach the less than 70 mg/dL goal.
2 or more risk factors listed above (and risk score* 10 – 20%) II. Next Highest Risk LDL level of less than 100mg/dl with option for drug therapy for those high-risk patients whose LDL is 100 to 129 mg/dL
2 or more risk factors (and risk score* less than 10%) III. Moderate Risk LDL goal of less than 130 mg/dl
0 or 1 risk factor IV. Low-to-Moderate Risk LDL goal of less than 160 mg/dl

Improve your cholesterol numbers

The new guidelines emphasize preventing heart disease in the short- and long-term, and recommend "therapeutic lifestyle changes (TLC)" to lower LDL. These involve:

  • Reducing saturated fat and cholesterol intake
  • Increasing intake of soluble fiber
  • Reducing weight if you are overweight - especially if you have metabolic syndrome (see below)
  • Increasing physical activity - regular physical activity is recommended for everyone.
  • Controlling high blood pressure
  • Quitting smoking

Working with a dietitian or nutritionist is extremely helpful.

Should I take cholesterol-lowering medication?

Drugs to reduce LDL include the "statins," bile acid sequestrants, nicotinic acid and fibric acid. If your LDL and heart-disease risk are both high, doctors may prescribe medications at the same time as lifestyle changes. For others, medication may be added if six to 12 weeks on the TLC plan fail to adequately reduce LDL. Those who are started on a cholesterol-lowering medication will need to continue lifestyle changes.

Identifying those with metabolic syndrome

A group of specific risk factors, known as the metabolic syndrome, raise your risk for coronary disease at any LDL cholesterol level. If you have three of the following risk factors, you may have metabolic syndrome, and need more rigorous cholesterol lowering:

  • Abdominal obesity (a waistline over 35 inches in women and 40 inches in men)
  • Triglycerides of 150 of higher
  • Low HDL (lower than 40 in men and lower than 50 in women)
  • Blood pressure of 130/85 mm Hg or higher
  • Fasting glucose of 110 mg/dL or higher

Middle-aged men (age 35 – 65) are predisposed to abdominal obesity and the metabolic syndrome. As a result, they carry a relatively high risk for heart disease. For those with high risk, intensive LDL reducing strategies should be followed.

See your doctor!

See your doctor. Ask for a complete lipoprotein profile. With results in hand and with your doctor's help, determine your risk for heart disease. If your cholesterol levels are not optimal, ask for a referral to a nutritionist, and begin your heart-healthy lifestyle right away.

To make an appointment:

You do not need a referral to make an appointment in the Preventive Cardiology Programs. For more information about cardiac risk factors and controlling high cholesterol, please contact the Preventive Cardiology and Rehabilitation Program at 216.444.9353 or toll-free 1-800-223-2273, extension 49353 to schedule a consultation.

For more information on implementing a low cholesterol diet, contact Preventive Cardiology Nutrition Program at 216.444.9353 or toll-free 1-800-223-2273, extension 49353 to schedule a consultation or utilize our remote Nutrition Counseling service*

For more information:

*a new browser window will open with this link. The inclusion of links to other web sites does not imply any endorsement of the material on the web sites or any association with their operators.

Reviewed: 12/2013

Talk to a Nurse: Mon. - Fri., 8:30 a.m. - 4 p.m. (ET)

Call a Heart & Vascular Nurse locally 216.445.9288 or toll-free 866.289.6911.

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This information is provided by Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition.

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