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High risk: Coronary heart disease (CHD) or CHD risk equivalent (10-year risk >20 percent) • <100 mg/dL (2.58 mmol/L); optional goal <70 mg/dL (1.82 mmol/L) in very high risk Δ ≥100 mg/dL (2.58 mmol/L) ◊ ≥ 100 mg/dL (2.58 mmol/L) § ; <100 mg/dL (2.58 mmol/L) consider drug options

Moderately high risk: 2 or more risk factors (10-year risk 10 to 20 percent) ¥ <130 mg/dL (3.36 mmol/L) ������ ≥130 mg/dL (3.36 mmol/L) ◊ ≥ ≥130 mg/dL (3.36 mmol/L); 100 to 129 mg/dL consider drug options ������

Lower risk: 0 to 1 risk factor** <160 mg/dL (4.13 mmol/L) ≥160 mg/dL (4.13 mmol/L) ≥190 mg/dL (4.91 mmol/L); 160 to 189 mg/dL consider drug options * When LDL lowering drug therapy is given, it is advised that the intensity of therapy be sufficient to achieve at least a 30 to 40 percent reduction in LDL levels. • CHD risk equivalents include noncoronary forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and carotid artery disease), and diabetes. Ten-year risk defined by modified Framingham risk score. Δ Very high risk favors the optional LDL goal of <70 mg/dL (1.82 mmol/L) and, in patients with high triglycerides, non-HDL cholesterol goal of <100 mg/dL. ◊ ≥ Any individual at high or moderately high risk who has lifestyle-related risk factors (eg, obesity, physical inactivity, hypertriglyceridemia, low HDL-cholesterol [<40 mg/dL (1.04 mmol/L)], or metabolic syndrome is a candidate for therapeutic lifestyle changes to modify these risk factors independent of LDL level. § If baseline LDL is <100 mg/dL (2.58 mmol/L), institution of an LDL lowering drug is an option. This can be combined with a fibrate or nicotinic acid if a high-risk person has hypertriglyceridemia or low HDL (<40 mg/dL (1.04 mmol/L). ¥ Risk factors that modify LDL goals include cigarette smoking; hypertension (BP ≥140/90 mmHg or on antihypertensive medication)s; low HDL-cholesterol (<40 mg/dL [1.03 mmol/L]); family history of premature CHD (CHD in male first degree relative <55 years or CHD in female first degree relative <65 years); age (men ≥45 years; women ≥55 years). HDL-cholesterol ≥60 mg/dL (1.55 mmol/L) counts as a negative risk factor; its presence removes one risk factor from the total count. ‡ Optional LDL goal <100 mg/dL (2.58 mmol/L). † For moderately high risk persons with LDL of 100 to 129 mg/dL (2.58 to 3.35 mmol/L) at baseline or after lifestyle changes, initiation of an LDL lowering drug to achieve an LDL <100 mg/L is an option. ** Almost all people with 0 to 1 risk factor have a 10-year risk <10 percent; thus, 10-year risk assessment in people with 0 to 1 risk factor is not necessary.

* When LDL lowering drug therapy is given, it is advised that the intensity of therapy be sufficient to achieve at least a 30 to 40 percent reduction in LDL levels. • CHD risk equivalents include noncoronary forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and carotid artery disease), and diabetes. Ten-year risk defined by modified Framingham risk score. Δ Very high risk favors the optional LDL goal of <70 mg/dL (1.82 mmol/L) and, in patients with high triglycerides, non-HDL cholesterol goal of <100 mg/dL. ◊ ≥ Any individual at high or moderately high risk who has lifestyle-related risk factors (eg, obesity, physical inactivity, hypertriglyceridemia, low HDL-cholesterol [<40 mg/dL (1.04 mmol/L)], or metabolic syndrome is a candidate for therapeutic lifestyle changes to modify these risk factors independent of LDL level. § If baseline LDL is <100 mg/dL (2.58 mmol/L), institution of an LDL lowering drug is an option. This can be combined with a fibrate or nicotinic acid if a high-risk person has hypertriglyceridemia or low HDL (<40 mg/dL (1.04 mmol/L). ¥ Risk factors that modify LDL goals include cigarette smoking; hypertension (BP ≥140/90 mmHg or on antihypertensive medication)s; low HDL-cholesterol (<40 mg/dL [1.03 mmol/L]); family history of premature CHD (CHD in male first degree relative <55 years or CHD in female first degree relative <65 years); age (men ≥45 years; women ≥55 years). HDL-cholesterol ≥60 mg/dL (1.55 mmol/L) counts as a negative risk factor; its presence removes one risk factor from the total count. ‡ Optional LDL goal <100 mg/dL (2.58 mmol/L). † For moderately high risk persons with LDL of 100 to 129 mg/dL (2.58 to 3.35 mmol/L) at baseline or after lifestyle changes, initiation of an LDL lowering drug to achieve an LDL <100 mg/L is an option. ** Almost all people with 0 to 1 risk factor have a 10-year risk <10 percent; thus, 10-year risk assessment in people with 0 to 1 risk factor is not necessary. Adapted from: Third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Circulation 2002; 106:3143; with modifications from Grundy SM, Cleeman JI, Merz CN, et al, Circulation 2004; 110:227.

©2013 UpToDate ® Print Email ATP III LDL-cholesterol goals and cutpoints for therapeutic lifestyle changes and drug therapy in different risk categories Risk category LDL-cholesterol goal LDL-cholesterol level at which to initiate therapeutic lifestyle changes LDL-cholesterol level at which to consider drug therapy Coronary heart disease (CHD) or CHD risk equivalent (10-year risk >20 percent)* <100 mg/dL (2.58 mmol/L) ≥100 mg/dL (2.58 mmol/L) ≥130 mg/dL (3.36 mmol/L); drug optional at 100 to 129 mg/dL (2.58 to 3.33 mmol/L)• 2 or more risk factors (10-year risk ≤20 percent)Δ ≤130 mg/dL (3.36 mmol/L) ≥130 mg/dL (3.36 mmol/L) 10-year risk 10 to 20 percent: >130 mg/dL (3.36 mmol/L) 10-year risk <10 percent: ≥160 mg/dL (4.13 mmol/L) 0 to 1 risk factor◊ ≤160 mg/dL (4.13 mmol/L) ≥160 mg/dL (4.13 mmol/L) ≥190 mg/dL (4.91 mmol/L); LDL-cholesterol lowering drug optional at 160 to 189 mg/dL (4.13 to 4.88 mmol/L) * CHD risk equivalents defined in text. 10-year risk defined by Framingham risk score (see text). • Some authorities recommend use of LDL-cholesterol lowering drugs in this category if LDL-cholesterol <100 mg/dL (2.58 mmol/L) cannot be achieved by therapeutic lifestyle changes. Others prefer use of drugs that primarily modify triglycerides and HDL-cholesterol (eg, nicotinic acid or fibrate). Clinical judgement may also call for deferring drug therapy in this subcategory. Δ Risk factors that modify LDL-cholesterol goals include cigarette smoking; hypertension (BP 140/90 mmHg or on antihypertensive medication); low HDL-cholesterol (<40 mg/dL [1.03 mmol/L]); family history of premature CHD (CHD in male first degree relative <55 years or CHD in female first degree relative <65 years); age (men 45 years; women 55 years). HDL-cholesterol 60 mg/dL (1.55 mmol/L) counts as a negative risk factor; its presence removes one risk factor from the total count. ◊ Almost all people with 0 to 1 risk factor have a 10-year risk <10 percent; thus, 10-year risk assessment in people with 0 to 1 risk factor is not necessary. Adapted from Adult Treatment Panel III at file://www.nhlbi.nih.gov/.

* When LDL lowering drug therapy is given, it is advised that the intensity of therapy be sufficient to achieve at least a 30 to 40 percent reduction in LDL levels. • CHD risk equivalents include noncoronary forms of atherosclerotic disease (peripheral arterial disease, abdominal aortic aneurysm, and carotid artery disease), and diabetes. Ten-year risk defined by modified Framingham risk score. Δ Very high risk favors the optional LDL goal of <70 mg/dL (1.82 mmol/L) and, in patients with high triglycerides, non-HDL cholesterol goal of <100 mg/dL. ◊ ≥ Any individual at high or moderately high risk who has lifestyle-related risk factors (eg, obesity, physical inactivity, hypertriglyceridemia, low HDL-cholesterol [<40 mg/dL (1.04 mmol/L)], or metabolic syndrome is a candidate for therapeutic lifestyle changes to modify these risk factors independent of LDL level. § If baseline LDL is <100 mg/dL (2.58 mmol/L), institution of an LDL lowering drug is an option. This can be combined with a fibrate or nicotinic acid if a high-risk person has hypertriglyceridemia or low HDL (<40 mg/dL (1.04 mmol/L). ¥ Risk factors that modify LDL goals include cigarette smoking; hypertension (BP ≥140/90 mmHg or on antihypertensive medication)s; low HDL-cholesterol (<40 mg/dL [1.03 mmol/L]); family history of premature CHD (CHD in male first degree relative <55 years or CHD in female first degree relative <65 years); age (men ≥45 years; women ≥55 years). HDL-cholesterol ≥60 mg/dL (1.55 mmol/L) counts as a negative risk factor; its presence removes one risk factor from the total count. ‡ Optional LDL goal <100 mg/dL (2.58 mmol/L). † For moderately high risk persons with LDL of 100 to 129 mg/dL (2.58 to 3.35 mmol/L) at baseline or after lifestyle changes, initiation of an LDL lowering drug to achieve an LDL <100 mg/L is an option. ** Almost all people with 0 to 1 risk factor have a 10-year risk <10 percent; thus, 10-year risk assessment in people with 0 to 1 risk factor is not necessary. Adapted from: Third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Circulation 2002; 106:3143; with modifications from Grundy SM, Cleeman JI, Merz CN, et al, Circulation 2004; 110:227. Definition of "very high risk" in NCEP guidelines Established coronary heart disease

Adapted from: Third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Circulation 2002; 106:3143; with modifications from Grundy SM, Cleeman JI, Merz CN, et al, Circulation 2004; 110:227. Definition of "very high risk" in NCEP guidelines Established coronary heart disease PLUS Multiple major risk factors (especially diabetes) OR Severe and poorly controlled risk factors (especially continued smoking) OR Multple risk factors of the metabolic syndrome (especially triglycerides ≥200 plus non-HDL-C ≥130 plus HDL-C <40) OR Acute coronary syndrome Adapted from Grundy SM, Cleeman JI, Merz NB, et al. Circulation 2004; 110:227.