Risk Category
High risk: CHD* or CHD risk equivalents¥ (10-year risk > 20%)
LDL-C Goal
< 100 mg/dL£ (optional goal: < 70 mg/dL)£
Initiate TLC
≥ 100 mg/dL#
Consider Drug Therapy**
≥ 100 mg/dL ££ (< 100 mg/dL: consider drug options)¥¥
TLC-Therapeutic Lifestyle Changes
* CHD includes history of myocardial infarction, unstable angina, stable angina, coronary artery procedures (angioplasty or bypass surgery), or evidence of clinically significant myocardial ischemia.
¥ CHD risk equivalents include clinical manifestations of noncoronary forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and carotid artery disease [transient ischemic attacks or stroke of carotid origin or > 50% obstruction of a carotid artery]), diabetes, and 2+ risk factors with 10-year risk for hard CHD > 20%.
£ Risk factors include cigarette smoking, hypertension (BP ≥ 140/90 mm Hg or on antihypertensive medication), low HDL cholesterol (< 40 mg/dL), family history of premature CHD (CHD in male first-degree relative < 55 years of age; CHD in female first-degree relative < 65 years of age), and age (men ≥ 45 years; women ≥ 55 years).
§ Almost all people with 0 or 1 risk factor have a 10-year risk < 10%, and 10-year risk assessment in people with 0 or 1 risk factor is thus not necessary.
¶ Very high risk favors the optional LDL-C goal of < 70 mg/dL, and in patients with high triglycerides, non-HDL-C < 100 mg/dL.
|| Optional LDL-C goal < 100 mg/dL.
# Any person at high risk or moderately high risk who has lifestyle-related risk factors (e.g., obesity, physical inactivity, elevated triglyceride, low HDL-C, or metabolic syndrome) is a candidate for therapeutic lifestyle changes to modify these risk factors regardless of LDL-C level.
¥¥ When LDL-lowering drug therapy is employed, it is advised that intensity of therapy be sufficient to achieve at least a 30% to 40% reduction in LDL-C levels.
££ If baseline LDL-C is < 100 mg/dL, institution of an LDL-lowering drug is a therapeutic option on the basis of available clinical trial results. If a high-risk person has high triglycerides or low HDL-C, combining a fibrate or nicotinic acid with an LDL-lowering drug can be considered.
**For moderately high-risk persons, when LDL-C level is 100-129 mg/dL at baseline or with lifestyle therapy, initiation of an LDL-lowering drug to achieve an LDL-C level < 100 mg/dL is a therapeutic option on the basis of available clinical trial results.
