Cholesterol (cont.)

Controlling blood cholesterol levels may decrease the risk of heart attack and stroke. The National Institute of Health, the American Heart Association and the American College of Cardiology publish guidelines to help physicians and patients with this risk reduction. The most recent consensus in 2004 recommended the following:

1. Consider more intensive LDL cholesterol-lowering for people at very high, high, and moderately high risk for a heart attack. For example, for patients with a very high risk of heart attacks, the LDL cholesterol treatment goal remains at <100mg/dl, but the report advised doctors to consider the option of lowering the LDL cholesterol (usually using a statin plus lifestyle changes) to <70 mg/dl.
2. Initiate therapeutic lifestyle changes to modify lifestyle-related risk factors (obesity, physical inactivity, metabolic syndrome, high blood triglyceride levels and low HDL cholesterol levels). Lifestyle changes have the potential to reduce heart attack and stroke risks through several mechanisms beyond the lowering of LDL cholesterol.
3. When LDL-lowering medication is used for very high, high or moderately high risk patients, the report advises that the intensity of LDL-lowering drug therapy be sufficient to achieve at least a 30 to 40 percent reduction in LDL cholesterol levels.
4. When a very high or high risk patient also has high blood triglyceride or low HDL cholesterol levels, doctors may consider combining nicotinic acid or a fibrate with a statin. Nicotinic acid and fibrates are more effective than statins in lowering triglycerides and increasing HDL.
5. Age should not be a consideration since older persons also benefit from lowering LDL cholesterol. It is never too late or the patient too old to begin lifestyle changes and medications to lower LDL cholesterol. A word of caution is in order. Elderly patients are more likely to have liver and kidney dysfunction, and are also more likely to be on multiple medications some of which may interfere with the breakdown of cholesterol-lowering drugs such as statins. Thus lower dosing may be necessary to avoid adverse side effects.

The 2004 NCEP treatment goals according to risk categories

Risk category	LDL goal	More intense LDL goal option	Initiate TLC if LDL is:	Consider drugs + TLC if LDL is:
High risk	<100 mg/dl		>100 mg/dl	>100 mg/dl
Very high risk	<100 mg/dl	<70 mg/dl	>100 mg/dl	>100 mg/dl
Moderately high risk (10 yr. risk 10%-20%)	<130 mg/dl	<100 mg/dl	>130 mg/dl	>130mg/dl, consider drug option if LDL is 100-129 mg/dl
Moderate risk (10 yr. risk <10%)	<130 mg/dl		>130 mg/dl	>160 mg/dl
Lower risk	<160 mg/dl		>160 mg/dl	>190 mg/dl, consider drug optional if LDL is 160-189 mg/dl

• High risk patients are those who already have coronary heart disease (such as a prior heart attack), diabetes mellitus, abdominal aortic aneurysm, or those who already have atherosclerosis of the arteries to the brain and extremities (such as patients with strokes, TIA's (mini-strokes), and peripheral vascular diseases). High risk patients also include those with 2 or more risk factors (for example, smoking, hypertension, or a family history of early heart attacks) that places them at a greater than 20 percent chance of having a heart attack within 10 years. (A person's chance of having a heart attack can be calculated by using the Framingham Heart Study Score Sheets, at http://nhlbi.nih.gov/about/framingham/riskabs.htm).
• Very high -risk patients are those who have coronary heart disease in addition to having either multiple risk factors (especially diabetes), or severe and poorly controlled risk factors (such as continued smoking), or metabolic syndrome (a constellation of risk factors associated with obesity, including high triglycerides and low HDL). Patients hospitalized for acute coronary syndromes are also at very high risk.
• Moderately high risk patients are those who have neither coronary heart disease nor diabetes mellitus, but have multiple (2 or more) risk factors for coronary heart disease that put them at a 10 to 20 percent risk of heart attack within 10 years. (Use the Framingham Heart Study Score Sheets, at http://nhlbi.nih.gov/about/framingham/riskabs,htm to calculate the 10 year risk.)
• Moderate risk patients are those who have neither CHD nor diabetes mellitus, but have 2 or more risk factors for coronary heart disease that put them at a <10% risk of heart attack within 10 years.
• Lower risk patients are those with 0 to 1 risk factor for coronary heart disease.

Source: MedicineNet.com
http://www.medicinenet.com/cholesterol/article.htm