LIPIDS

See Prescribing Notes at the beginning of this Section for more information.
• Lowering LDL-C is the main goal of treatment; once the LDL-C goal is reached, other lipid and non-lipid risk factors can be
treated. Therapeutic Lifestyle Changes (TLC) are first-line therapy; reserve drug therapy for higher risk patients. Continue TLC
for ⱖ3 months before starting drug therapy; use drug therapy with—not instead of—TLC.
• If there is evidence of coronary heart disease (CHD) or CHD risk equivalents, do lipoprotein analysis.
• If there is no evidence of CHD, but there are 2 or more major risk factors for CHD other than LDL-C, use Framingham scoring
system to identify those whose 10-year risk (% probability of having a CHD event in 10 years) warrants consideration of
intensive treatment. See www.nhlbi.nih.gov for worksheets to determine 10-year risk.
LDL-C GOALS
LDL-C level to
Risk Category LDL-C goal start TLC LDL-C level to consider drug therapy
CHD or CHD risk equivalents ⬍100 mg/dL ⱖ100 mg/dL ⱖ100 mg/dL
(10-year risk ⬎20%) (optional goal <100 mg/dL: consider initiating or
of ⬍70 mg/dL) intensifying LDL-C lowering therapy,
treat other risk factors, or use other
lipid-modifying drugs (nicotinic acid or
fibrates) if high TG or low HDL-C
2⫹ risk factors (10-year risk 10 to 20%) ⬍130 mg/dL ⱖ130 mg/dL ⱖ130 mg/dL
(optional goal 100–129 mg/dL: consider initiating
of ⬍100 mg/dL) LDL-C lowering therapy optional
2⫹ risk factors (10-year risk ⬍10%) ⬍130 mg/dL ⱖ130 mg/dL ⱖ160 mg/dL
0 to 1 risk factor ⬍160 mg/dL ⱖ160 mg/dL ⱖ190 mg/dL
(10-year risk assessment not necessary) 160–189 mg/dL: drug therapy optional;
consider if single severe risk factor,
multiple life-habit and/or emerging risk
factors, or 10-year risk nearly 10%
LDL-C vs. Non-HDL-C Goals*
• In high-risk persons, consider drug therapy to achieve non-HDL-C goal. The non-HDL-C goal can be achieved by intensifying
therapy with an LDL-lowering drug or by cautiously adding nicotinic acid or fibrate.
Risk Category LDL-C Goal Non-HDL-C Goal
CHD and CHD risk equivalent ⬍100 mg/dL ⬍130 mg/dL
(10-year risk ⬎20%)
2⫹ risk factors and 10-year risk ⱕ20% ⬍130 mg/dL ⬍160 mg/dL
0 to 1 risk factor ⬍160 mg/dL ⬍190 mg/dL
*Non-HDL-C ⫽ Total-C ⫺ HDL-C
Management of Low HDL-C
• Low HDL-C (⬍40 mg/dL) is a strong independent predictor of CHD. The primary target of therapy is LDL-C. There is not a
specific goal for raising HDL-C; after LDL-C goal is reached, emphasize weight reduction and increased physical activity, and
modifying non-HDL-C if TG is also elevated.
• If triglycerides are ⬍200 mg/dL (see below), consider using drugs to raise HDL-C (fibrates or nicotinic acid).
Management of Elevated TG
• Elevated serum triglycerides (TG) is an independent risk factor for CHD. For all patients with high TG, the primary goal of
therapy is to achieve the target goal for LDL-C.
Classification Serum TG level In addition to achieving target LDL-C goal:
Normal ⬍150 mg/dL
Borderline-high 150–199 mg/dL • Reduce weight and increase physical activity
High 200–499 mg/dL • Non-HDL-C is secondary target (intensify LDL-C lowering
therapy or add nicotinic acid or fibrate cautiously).
Very High ⱖ500 mg/dL • Initial aim is to prevent acute pancreatitis through TG
lowering by using very low fat diets, weight reduction,
increased physical activity, and a TG lowering drug (fibrate
or nicotinic acid). After TG levels ⱕ500 mg/dL, focus on
lowering LDL-C.
Adapted by Prescribing Reference, Inc. from the Third Report of the NCEP Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults (ATP III), NIH pub no. 110:227–239, July 2004. All rights reserved. (Rev. 3/2005)