The AHA Guidelines and Scientific Statements Handbook

Chapter 10 Cholesterol Management in the Context of Risk Factor Profi le

Goals for cholesterol lowering therapy
Goals of therapy follow the principle that the higher
the risk of the patients, the more intensive should be
the risk-reduction therapy. The updated goals for
cholesterol-lowering therapy are shown in Table
10.3. Evidence level for each goal is given in the
footnotes to Table 10.3.

Role of other risk factors in risk assessment
ATP III recognizes that risk for CHD, as well as
CVD, is infl uenced by other factors not included
among the major, independent risk factors (Table
10.4). Among these are life-habit risk factors and
emerging risk factors. The former include obesity,
physical inactivity, and atherogenic diet; and the
latter consist of lipoprotein(a) [Lp(a)], homocyste-
ine, prothrombotic and proinfl ammatory factors,
impaired fasting glucose, and evidence of subclinical
atherosclerotic disease. The life-habit risk factors are
direct targets for clinical intervention, but are not
used to set a lower LDL-C goal of therapy. The
emerging risk factors do not categorically modify
LDL-C goals; however, they appear to contribute to
CVD risk to varying degrees and can have utility in
selected persons to guide intensity of risk-reduction
therapy. Their presence thus can modulate clinical
judgment when making therapeutic decisions based
physician discretion.

Secondary causes of lipid disorders

Any person with elevated LDL-C or other form of

hyperlipidemia should undergo clinical or labora-

tory assessment to rule out secondary dyslipidemia

before initiation of lipid-lowering therapy. Causes of

secondary dyslipidemia include:

• Diabetes


• Hypothyroidism


• Obstructive liver disease


• Chronic renal failure


• Drugs that raise LDL-C and lower HDL-C (pro-
  gestins, anabolic steroids, and corticosteroids).
  Once secondary causes have been excluded or, if
  appropriate, treated, the goals for LDL-lowering
  therapy in prevention are established according to a
  person’s risk category (Table 10.3).

Therapeutic approaches to cholesterol-

lowering therapy

Cholesterol-management guidelines focus on goals

of therapy [1–3]. The primary target of therapy is

LDL-C. Non-HDL-C is a secondary target in patients

with plasma triglycerides ≥200 mg/dL. However,

Table 10.3 Categories of risk that modify LDL-cholesterol goals

Risk category

LDL goal

(mg/dL)

Non-HDL-C Goal

(mg/dL)

Very high risk < 70 a < 100 a
High risk < 100 b < 130 a
Moderately
high risk

< 130 c (Optional < 100 d) < 160 c (Optional < 130 d)

Moderate risk < 130 e < 160 e
Lower risk < 160 f < 190 f

a Level of Evidence B.
b Level of Evidence A.
c Level of Evidence A.
d Level of Evidnece B.
e Level of Evidence A.
f Level of Evidence B.

Table 10.4 Nutrient composition of the cholesterol-lowering diet

Nutrient Recommended intake

Saturated fat* Less than 7% of total calories

Polyunsaturated fat Up to 10% of total calories

Monounsaturated fat Up to 20% of total calories

Total fat 25–35% of total calories

Carbohydrate† 50 to 60% of total calories

Fiber 20–30 grams per day

Protein Approximately 15% of total calories

Cholesterol Less than 200 mg/day

Total calories (energy)‡ Balance energy intake and expenditure to

maintain desirable body weight/

prevent weight gain

* Trans fatty acids are another LDL-raising fat that should be kept at a low

intake.

† Carbohydrate should be derived predominantly from foods rich in com-

plex carbohydrates including grains, especially whole grains, fruits, and

vegetables.

‡ Daily energy expenditure should include at least moderate physical activity

(contributing approximately 200 Kcal per day).