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New Cholesterol Guidelines Suggest More Aggressive Control of Risk Factors

March / April 2002

The recently published National Cholesterol Education Program (NCEP), Adult Treatment Panel (ATP) III, guidelines include important changes about more aggressive control of risk factors for the clinical management of high blood cholesterol. "Ninety percent of the people affected by these changes are under the care of a primary care physician. New recommendations suggest that many more people need medication and lifestyle changes," explains Muredach Reilly, MD, a cardiologist who specializes in preventive cardiology and is part of Penn's Cardiovascular Risk Intervention Program.

Patients are divided into three risk categories for coronary heart disease (CHD): 1) those with established CHD or its equivalent, 2) those with two or more traditional cardiac risk factors and 3) those with one or less risk factors. Risk factors include: smoking, hypertension, low HDL of less than 40 mg/dL (previously was less than 35 mg/dL), family history, and gender. This tighter criteria for what is considered a low HDL means more Americans are at risk than compared to the previous guidelines.

The most at-risk group is those with CHD or CHD equivalent - people with peripheral arterial disease, and for the first time, diabetes. "Because diabetes is such a strong risk factor on its own, these patients are being treated as if they already have CHD," adds Dr. Reilly.

The second broad category is further broken down into three groups by calculating the patient's Framingham Risk Score: those with greater than 20 percent, 10 to 20 percent, and less than 10 percent risk of CHD over 10 years. "Although this is an extra step in the patient evaluation, it is critical in determining those at greatest CHD risk in this second category," says Dr. Reilly. Patients with greater than 20 percent risk are treated as having CHD equivalent and receive the same treatment as patients with known CHD.

To reach the target LDL (which is different for each category), physicians recommend diet and exercise, sometimes combined with a statin drug. "If you have identified someone who is at risk and they are unable to get to their target LDL after six to 12 weeks, they should be referred to a lipid specialist or a cardiologist who specializes in CHD prevention," explains Dr. Reilly.

Lifestyle recommendations include reducing intake of saturated fats (less than seven percent fat) and cholesterol (less than 200/mg/day of cholesterol), using healthy vegetable fats, exercising, and losing weight. "Patients who are fairly sedentary at baseline, overweight, and have a poor diet will significantly lower their cholesterol if they modify their lifestyle. It's cheaper, safer, and more natural," says Dr. Reilly. He also recommends using medications initially only if the patient is at very high risk.

A patient admitted with acute coronary syndromes (ACS) is at very high risk for a future cardiac event and his cholesterol should be measured within 24 hours to obtain an accurate reading. Because in practice this is challenging, new guidelines support starting cholesterol-lowering statin drug therapy in the hospital if a patient's cholesterol is not known. This approach may, in fact, prevent recurrent CHD events within one month of hospitalization.

For the first time, ATP guidelines acknowledge that a prediabetic state, known as metabolic syndrome, can increase the risk of future heart disease. Physicians should be aggressive with lipid abnormalities and lifestyle in these patients. Also, women should not be prescribed hormone replacement therapy solely to prevent strokes and heart disease, because of conflicting evidence regarding CHD benefit.

	Referring Physicians: To speak with a Penn physician or refer a patient, contact PennHealth through the secure online referral form or by calling 1-800-789-PENN (7366).