Table 241-1. Major Risk Factors (Exclusive of LDL Cholesterol) that Modify LDL Goals Cigarette smoking Hypertension (BP 2140/90 mmHg or on anthypertensive medication) Low HDL cholesterol® [<1.0 mmol/L (<40 mg/dL)] Diabetes mellitus Family history of premature CHD CHO in male first-degree relative <55 years CHD in female first-degree relative <65 years JAge (men 245 years; women 255 years) Lifestyle risk factors Obesity (BMI 230 kg/m") Physical inactivity Atherogenic diet Emerging risk factors Lipoprotein(a) Homocysteine Prothrombotic factors Proinflammatory factors Impaired fasting glucose Subclinical atherosclerosis, “HDL cholesterol 21.6 mmol/L (260 mg/dL) counts as a “negative” risk factor; its presence removes one risk factor from the total count.‘Table 241-2. LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC) and Drug Therapy in Different Risk Categories LDL Level, mmol/L (mg/dL) Risk Category Goal Initiate TLC [Consider Drug Therapy Very high <1.8 (<70) 21.6 (270) [21.8 (270) |ACS, oF CHD w/OM, or multiple CRES Hon <2.6 (<100) 22.6 (2100) [22.6 (2100) [<2.6 (<100): consider drug Rx] IFLOL <2.6 (<100) [optional goal: <1.8 (<70)] <1.8 (<70) Moderately high <26 (<100) 23.4 (2130) zs (2130) [2.6-3.3 (100-129): consider drug Rx 2+ risk factors (20-year risk, 10- 20%) Moderate 3.4 (<130) 23.4 (2130) [24.1 (2160) 2s risk factors (tisk <10%) Loner <4.1 (<160) 24.1 (2160) [24.9 (2190) 0-1 risk factor Abbreviations: ACS, scuts coronzry syndrome; CHD, coronary heart disease; CRFS, coronary risk factors; DM, diabetes mellitus; LDL, low density lipoprotein236 © Circulation —_‘Suly 13, 2004 TABLE 2. ATP Ill LDL-C Goals and Cutpoints for TLC and Drug Therapy in Different Risk Categories and Proposed Modifications Based on Recent Clinical Trial Evidence Risk Catenory LLC Gal Initiate TLC ‘Consier Drug Therapy ig rik: GHD" or OAD isk equvalentst -<100 mold 100 my/eLt 100 myeht (10-year tisk > 20%) (optional goal: <70 mg/dl)| (<100 mg/L: consider drug options}** Moderately hgh se 2+ rk ects <130 mal 2130 mye 190 mye (10-year tsk 10% tb 20865 (100-129 gil; conser cup ction) Modeate risk: 2+ isk factors (10-year <130 mgd =130 mye = 160 moet risk <109055 Lower dist 4 isk factors -<160 mold 2160 mg/él 190 mye (161-189 mgil: LDLowerng drug optional) “OAD includes history of myocardial infarcton, unstable angina, stable angina, coronary artery procedures angioplasty or bypass suger, or evidence of cincaly sionicant nycarda ischemia. +¢CHO risk equierts ince cinical manifestation of nncornary fos of atherosclerotic csease (perpheral ater disease, abdominal zac aneurysm, znd ‘cantare disease [Transient ischemic attacks or stoke of carotid origin cr >S0% cbstucton ofa cacid artery), diabetes, and 2+ risk factors with 10-year tisk ‘or hard CHD >20%. +s factors incuds cigarette smcking, hypertension @P = 1400 mmHg or en anthypertenive medicaonl, lt HDL cholesterol (40 mov, family history of premature CHD (CHO in mae frst degre relatve <55 years of age; CHD in female first-degree rete <65 years of age), and age men =45 years; women 255 years). ‘§€Electonic 10-year isk calculators ae avalable at www ahbinh goviguidetnes/cnoesera, ‘mos al people with 20 oF 1 sk factor havea 10-year risk <10%, and 10-year risk assessmentin people wth zero or 1 risk factors thus not necessary [Nery tigh rk favors the cptonal LDL-C goal of <70 moj/dL, and in tients with igh tiycerides, non-HOL-C <100 mold. ‘$Opional LDL-C goal <100 mg‘. -#any person thigh risk or moderately igh isk who has Hfestyle-elated risk factors (9, obey, physicalnacty, elevated tigcerde, low HDL-C, or metebalic ‘sndtome| isa candidate fr therapeutic fest changes tb modity these rik factors regardless of LDL-C leva. "When LOLlowering drug theepy is employed, fis advse that intnsty of therapy te sunt to acteve atleast a 30% to 40% reducon in LDL-C levels. ‘if baseline LOL-Cis <100 mg/d, instittion of an LOL-onering dug isa therapevtc option on the bass of avalablecnical trl resuts. If high-sk person has high rilycerides or low HDL-C, combining a irate or nicotinic cid wit an LOL-owering crug can te considered. -HFer moderately high-tsk persons, wten LDL-C level i 100 to 129 mjd, at basen or on este therapy, intafon cf an LOLowerng cru ty active an LDL-C level <100 mo/dl is a therapeutic option on the basis of available clinical trial results.