Program
Risk Assessment
Count major risk factors
For patients with multiple (2+) risk factors
Perform 10-year risk assessment
For patients with 01 risk factor
10 year risk assessment not required
Most patients have 10-year risk <10%
Step 1: Age
Years
20-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
Points
if Untreated
0
0
1
1
2
Points
if Treated
0
1
2
2
3
Points at
Age 20-39
0
4
7
9
11
Step 3: HDL-Cholesterol
HDL-C
(mg/dL)
60
Points
-1
50-59
40-49
<40
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Step 7: CHD Risk
Smoking status
Point Total 10-Year Risk Point Total 10-Year Risk
Point
<0
<1% total
11
8%
0
1%
12
10%
1
1%
13
12%
2
1%
14
16%
3
1%
15
20%
4
1%
16
25%
5
2%
17
30%
6
2%
7
3%
8
4%
9
5%
10
6%
Nonsmoker
Smoker
Points at
Age 20-39
0
8
Note: Risk estimates were derived from the experience of the Framingham Heart Study,
a predominantly Caucasian population in Massachusetts, USA.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.
JAMA. 2001;285:2486-2497.
10
Step 1: Age
Years
20-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
Points
-7
-3
0
3
6
8
10
12
14
16
Points
if Untreated
0
1
2
3
4
Points
if Treated
0
3
4
5
6
Points at
Age 20-39
0
4
8
11
13
Step 3: HDL-Cholesterol
HDL-C
(mg/dL)
60
Points
-1
50-59
40-49
<40
Age
Total cholesterol
HDL-cholesterol
Systolic blood pressure
Step 7: CHD Risk
Smoking status
Point Total 10-Year Risk Point Total 10-Year Risk
Point
<9
<1% total
20
11%
9
1%
21
14%
10
1%
22
17%
11
1%
23
22%
12
1%
24
27%
13
2%
25
30%
14
2%
15
3%
16
4%
17
5%
18
6%
19
8%
Nonsmoker
Smoker
Points at
Age 20-39
0
9
Note: Risk estimates were derived from the experience of the Framingham Heart Study,
a predominantly Caucasian population in Massachusetts, USA.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.
JAMA. 2001;285:2486-2497.
Men
Years
20-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
11
Step 1: Age
Points
-9
-4
0
3
6
8
10
11
12
13
Years
20-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
Women
Points
-7
-3
0
3
6
8
10
12
14
16
12
Points at
Age 20-39
0
4
7
9
11
Points at
Age 40-49
0
3
5
6
8
Points at
Age 50-59
0
2
3
4
5
Points at
Age 60-69
0
1
1
2
3
Points at
Age 70-79
0
0
0
1
1
Points at
Age 20-39
0
4
8
11
13
Points at
Age 40-49
0
3
6
8
10
Points at
Age 50-59
0
2
4
5
7
Points at
Age 60-69
0
1
2
3
4
Points at
Age 70-79
0
1
1
2
2
Women
TC
(mg/dL)
<160
160-199
200-239
240-279
280
Note: TC and HDL-C values should be the average of at least two fasting
lipoprotein measurements.
Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults. JAMA. 2001;285:2486-2497.
13
Step 3: HDL-Cholesterol
Men
HDL-C
(mg/dL)
60
Women
Points
-1
HDL-C
(mg/dL)
60
Points
-1
50-59
50-59
40-49
40-49
<40
<40
14
Systolic BP
Points
(mm Hg) if Untreated
<120
0
120-129
0
130-139
1
140-159
1
160
2
Women
Systolic BP
(mm Hg)
<120
120-129
130-139
140-159
160
Points
if Treated
0
1
2
2
3
Points
if Untreated
0
1
2
3
4
Points
if Treated
0
3
4
5
6
15
Points at
Points at
Age 20-39 Age 40-49
0
0
8
5
Points at
Age 50-59
0
3
Points at
Age 60-69
0
1
Points at
Age 70-79
0
1
Points at
Points at
Age 20-39 Age 40-49
0
0
9
7
Points at
Age 50-59
0
4
Points at
Points at
Age 60-69 Age 70-79
0
0
2
1
Women
Nonsmoker
Smoker
16
17
10-Year Risk
<1%
1%
1%
1%
1%
1%
2%
2%
3%
4%
5%
6%
Point Total
11
12
13
14
15
16
17
Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death)
from point total.
10-Year Risk
8%
10%
12%
16%
20%
25%
30%
18
10-Year Risk
<1%
1%
1%
1%
1%
2%
2%
3%
4%
5%
6%
8%
Point Total
20
21
22
23
24
25
Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death)
from point total.
10-Year Risk
11%
14%
17%
22%
27%
30%
19
20
21
22
23
<100
<130
<160
Optimal
100129
130159
Borderline high
160189
High
190
Very high
24
25
Low
60
High
26
27
28
Risk Category
CHD or CHD Risk
Equivalents
(10-year risk >20%)
2+ Risk Factors
(10-year risk 20%)
01 Risk Factor
LDL Goal
(mg/dL)
<100
100
130
(100129: drug
optional)
10-year risk 1020%:
130
<130
130
10-year risk <10%:
160
<160
160
190
(160189: LDLlowering drug
optional)
29
LDL Goal
130 mg/dL
<100 mg/dL
100 mg/dL
(100129 mg/dL:
drug optional)
30
31
LDL Goal
<130 mg/dL
130 mg/dL
10-year risk <10%:
160 mg/dL
LDL Goal
<160 mg/dL
160 mg/dL
(160189 mg/dL:
LDL-lowering drug
optional)
32
33
34
35
36
37
38
39
40
41
42
Recommended Intake
Monounsaturated fat
Total fat
Carbohydrate
Fiber
Protein
43
A Model of Steps in
Therapeutic Lifestyle Changes (TLC)
Visit I
Begin Lifestyle
Therapies
6 wks
Emphasize
reduction in
saturated fat &
cholesterol
Encourage
moderate physical
activity
Consider referral to
a dietitian
Visit 2
Evaluate LDL
response
6 wks
Visit 3
Evaluate LDL
response
If LDL goal not
achieved, consider
adding drug Tx
Initiate Tx for
Metabolic
Syndrome
Intensify weight
management &
physical activity
Consider referral
to a dietitian
Q 4-6 mo
Visit N
Monitor
Adherence
to TLC
44
Steps in Therapeutic
Lifestyle Changes (TLC)
First Visit
Begin Therapeutic Lifestyle Changes
Emphasize reduction in saturated fats and cholesterol
Initiate moderate physical activity
Consider referral to a dietitian (medical nutrition
therapy)
Return visit in about 6 weeks
45
Steps in Therapeutic
Lifestyle Changes (TLC) (continued)
Second Visit
Evaluate LDL response
Intensify LDL-lowering therapy (if goal not achieved)
Reinforce reduction in saturated fat and cholesterol
Consider plant stanols/sterols
Increase viscous (soluble) fiber
Consider referral for medical nutrition therapy
Return visit in about 6 weeks
46
Steps in Therapeutic
Lifestyle Changes (TLC) (continued)
Third Visit
Evaluate LDL response
Continue lifestyle therapy (if LDL goal is achieved)
Consider LDL-lowering drug (if LDL goal not achieved)
Initiate management of metabolic syndrome
(if necessary)
Intensify weight management and physical activity
Consider referral to a dietitian
47
Drug Therapy
HMG CoA Reductase Inhibitors (Statins)
Reduce LDL-C 1855% & TG 730%
Raise HDL-C 515%
Major side effects
Myopathy
Increased liver enzymes
Contraindications
Absolute: liver disease
Relative: use with certain drugs
48
49
Drug Therapy
Bile Acid Sequestrants
Major actions
Reduce LDL-C 1530%
Raise HDL-C 35%
May increase TG
Side effects
GI distress/constipation
Decreased absorption of other drugs
Contraindications
Dysbetalipoproteinemia
Raised TG (especially >400 mg/dL)
50
51
Drug Therapy
Nicotinic Acid
Major actions
Lowers LDL-C 525%
Lowers TG 2050%
Raises HDL-C 1535%
Side effects: flushing, hyperglycemia, hyperuricemia,
upper GI distress, hepatotoxicity
Contraindications: liver disease, severe gout, peptic
ulcer
52
53
Drug Therapy
Fibric Acids
Major actions
Lower LDL-C 520% (with normal TG)
May raise LDL-C (with high TG)
Lower TG 2050%
Raise HDL-C 1020%
Side effects: dyspepsia, gallstones, myopathy
Contraindications: Severe renal or hepatic disease
54
55
56
57
Start statin or
bile acid
sequestrant
or nicotinic
acid
6 wks
Consider higher
dose of statin or
add a bile acid
sequestrant or
nicotinic acid
6 wks
If LDL goal
achieved, treat
other lipid risk
factors
Q 4-6 mo
Monitor
response and
adherence to
therapy
58
59
60