mnt in cardiovascular disease. prevalence and incidence the united states ranks 14th and 16th, among...
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MNT in MNT in Cardiovascular Cardiovascular DiseaseDisease
Prevalence and Prevalence and IncidenceIncidence The United States ranks 14th and 16th, The United States ranks 14th and 16th,
among industrialized nations for the among industrialized nations for the prevalence of CVD in women and men, prevalence of CVD in women and men, respectively.respectively.
More than 61 million Americans have at least More than 61 million Americans have at least one form of CVD (i.e., hypertension, CHD, one form of CVD (i.e., hypertension, CHD, stroke, rheumatic heart disease, or stroke, rheumatic heart disease, or congestive heart failure).congestive heart failure).
The incidence of CHD is high; an American The incidence of CHD is high; an American experiences a coronary event almost every experiences a coronary event almost every 29 seconds.29 seconds.
Leading Causes of Leading Causes of DeathDeathU.S. 2000U.S. 2000
From http://www.nhlbi.nih.gov/resources/docs/02_chtbk.pdf; accessed 3-05
Percentage Breakdown of Deaths From Cardiovascular DiseasesUnited States:2002 Preliminary
Source: CDC/NCHS.
18%
6%
5%
4%0%0%
13%
53%
Coronary Heart Disease
Stroke
Congestive Heart Failure
High Blood Pressure
Diseases of the Arteries
Rheumatic Fever/RheumaticHeart Disease
Congenital CardiovascularDefects
Other
Prevalence of Coronary Heart Diseases by Age and SexNHANES :1999-2002
Source: CDC/NCHS and NHLBI.
0.01.4
3.0
16.8
0.31.6
3.6
11.611.5
6.3
10.3
0.20
5
10
15
20
20-34 35-44 45-54 55-64 65-74 75+
Ages
Perc
ent o
f Pop
ulat
ion
Men Women
Annual Number of Americans Having Diagnosed Heart Attack by Age and SexARIC: 1987-2000
Source: Extrapolated from rates in the NHLBI’s ARIC surveillance study, 1987-2000. These data don’t include silent MIs.
34,000
250,000
10,000
410,000 372,000
88,000
0
100,000
200,000
300,000
400,000
500,000
29-44 45-64 65+
Ages
New
and
Rec
urre
nt A
ttac
ks
Men Women
Prevalence of Stroke by Age and Sex
NHANES: 1999-2002
Source: CDC/NCHS and NHLBI.
1.1
3.1
6.6
11.5
0.41.2
12.0
0.3 0.82.1
3.0
6.3
0
2
4
6
8
10
12
14
20-34 35-44 45-54 55-64 65-74 75+
Ages
Per
cen
t o
f P
op
ula
tio
n
Men Women
`
Prevalence of High Blood Pressure in Americans by Age and SexNHANES: 1999-2002
Source: CDC/NCHS and NHLBI.
11.121.3
34.1
5.8
55.5
74.0
46.6
60.969.2
18.1
34.0
83.4
0
20
40
60
80
100
20-34 35-44 45-54 55-64 65-74 75+
Ages
Pe
rce
nt
of
Po
pu
lati
on
Men Women
Prevalence of Congestive Heart Failure by Age and SexNHANES: 1999-2002
Source: CDC/NCHS and NHLBI.
5.8 6.2
9.8
1.50.3 0.5
1.8 2.3
10.9
4.1
0.40.3
0
2
4
6
8
10
20-34 35-44 45-54 55-64 65-74 75+
Ages
Per
cent
of P
opul
atio
n
Men Women
Cardiovascular Disease Mortality Trends Cardiovascular Disease Mortality Trends for Males and Females for Males and Females United States: 1979-2002United States: 1979-2002
Source: CDC/NCHS.
380400420440460480500520
Years
Dea
ths
in T
hous
ands
Males Females
CVD in Men and CVD in Men and WomenWomen CVD mortality in men is holding CVD mortality in men is holding
steady; in women it is increasingsteady; in women it is increasing Women have comparable CVD rates Women have comparable CVD rates
about 10-15 years later than men, about 10-15 years later than men, but the gap diminishes with agebut the gap diminishes with age
82% of coronary events in women are 82% of coronary events in women are attributable to unhealthy diet, lack of attributable to unhealthy diet, lack of activity, cigarette use, and activity, cigarette use, and overweightoverweight
CVD in WomenCVD in Women
Women post MI are less likely to Women post MI are less likely to receive aspirin, beta-blockers, receive aspirin, beta-blockers, intravenous heparin, or nitrate intravenous heparin, or nitrate therapies within the first 24 hours of therapies within the first 24 hours of hospital admission hospital admission
They were less likely to undergo They were less likely to undergo coronary angiography, angioplasty, or coronary angiography, angioplasty, or bypass surgery, but they were more bypass surgery, but they were more likely to die in the hospital. likely to die in the hospital.
CVD in WomenCVD in Women
Women have a higher prevalence of Women have a higher prevalence of white-coat hypertension than men. white-coat hypertension than men.
Women may have atypical symptoms Women may have atypical symptoms when suffering a heart attack or when suffering a heart attack or angina angina
When they are sent home from the When they are sent home from the hospital, they are more than twice as hospital, they are more than twice as likely to die as those who are likely to die as those who are admittedadmitted
A Nation at RiskA Nation at Risk
49 million Americans smoke 49 million Americans smoke 42 million have total cholesterols 42 million have total cholesterols
>240 mg/dl>240 mg/dl 63 million have total cholesterols 63 million have total cholesterols
200-239200-239 17 million Americans have diabetes17 million Americans have diabetes 61 million Americans are obese; 68 61 million Americans are obese; 68
million are overweightmillion are overweight
There is Encouraging There is Encouraging News!News!
Framingham Framingham MilestonesMilestones 1960: cigarette smoking found to 1960: cigarette smoking found to
increase the risk of heart diseaseincrease the risk of heart disease 1961: Cholesterol level, blood 1961: Cholesterol level, blood
pressure, and EKG abnormalities found pressure, and EKG abnormalities found to increase the risk of heart diseaseto increase the risk of heart disease
1967: physical activity found to reduce 1967: physical activity found to reduce the risk of heart disease; obesity found the risk of heart disease; obesity found to increase the risk of heart diseaseto increase the risk of heart disease
1970: High blood pressure found to 1970: High blood pressure found to increase the risk of strokeincrease the risk of stroke
Framingham Framingham MilestonesMilestones 1976: Menopause found to increase 1976: Menopause found to increase
the risk of heart diseasethe risk of heart disease 1978: Psychosocial issues found to 1978: Psychosocial issues found to
affect the risk of heart diseaseaffect the risk of heart disease 1988: High levels of HDL found to 1988: High levels of HDL found to
reduce risk of deathreduce risk of death 1994: Enlarged left ventricle found to 1994: Enlarged left ventricle found to
increase the risk of strokeincrease the risk of stroke 1996: Progression from hypertension 1996: Progression from hypertension
to heart failure describedto heart failure described
Favorable TrendsFavorable Trends
Over past 30 years, mortality and Over past 30 years, mortality and in-hospital case fatality has in-hospital case fatality has declined 50%declined 50%
Prevalence of risk factors of Prevalence of risk factors of smoking, hypertension, high smoking, hypertension, high cholesterol has declined 25 to cholesterol has declined 25 to 46%46%
0
10
20
30
40
50
60
Cigarette smoking among men, women, high school students, and mothers during pregnancy: United States, 1965-2003
NOTES: Percents for men and women are age adjusted. See Data Table for data points graphed, standard errors, and additional notes. Cigarette smoking is defined as: (for men and women 18 years of age and older) at least 100 cigarettes in lifetime and now smoke every day or some days; (for students in grades 9-12) 1 or more cigarettes in the 30 days preceding the survey; and (for mothers with a live birth) during pregnancy.
SOURCES: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey (data for men and women); National Vital Statistics System (data for mothers during pregnancy); National Center for Chronic Disease Prevention and Health Promotion, Youth Risk Behavior Survey (data for high school students).
Men
Women
Mothers during pregnancy
High school students
Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004
Per
cen
t
1965 1970 1975 1980 1985 1990 1995 2003
Year
Percent of Population 20-74 Percent of Population 20-74 with High Serum Cholesterol by with High Serum Cholesterol by Race and Sex 1971-74 to 1988-Race and Sex 1971-74 to 1988-9494
http://www.nhlbi.nih.gov/resources/docs/02_chtbk.pdf accessed 3-05
0
10
20
30
40
50
60
70
THE BAD NEWS: Overweight and obesity by age: United States, 1960-2002
NOTES: Percents for adults are age adjusted. For adults: "overweight including obese" is defined as a body mass index (BMI) greater than or equal to 25, "overweight but not obese" as a BMI greater than 25 but less than 30, and "obese" as a BMI greater than or equal to 30. For children: "overweight" is defined as a BMI at or above the sex- and age-specific 95th percentile BMI cut points from the 2000 CDC Growth Charts: United States. "Obese" is not defined for children. See Data Table for data points graphed, standard errors, and additional notes. Data are for the civilian noninstitutionalized population and are age adjusted. See Data Table for data points graphed and additional notes.
SOURCES: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Examination Survey and National Health and Nutrition Examination Survey.
Overweight including obese, 20-74 years
Overweight, 6-11 years
Overweight, 12-19 years
Overweight, but not obese, 20-74 years
Obese, 20-74 years
Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004
1960-62 1963-65 1966-70 1971-74 1976-80 1988-94
1999-2002
Year
The Decrease in CVD The Decrease in CVD MortalityMortality 25% is due to primary prevention25% is due to primary prevention 75% is due to behavioral changes 75% is due to behavioral changes
affecting risk factors or affecting risk factors or improvements in treatmentimprovements in treatment
Benefits of Risk Factor Benefits of Risk Factor ReductionReduction 50-70% lower risk in former vs current 50-70% lower risk in former vs current
smokers within 5 years of cessationsmokers within 5 years of cessation 2-3% decline in risk for each reduction 2-3% decline in risk for each reduction
of 1% serum cholesterolof 1% serum cholesterol 2-3% decline in risk for each reduction 2-3% decline in risk for each reduction
of 1 mm Hg in diastolic blood pressureof 1 mm Hg in diastolic blood pressure 35-55% lower risk for those who 35-55% lower risk for those who
maintain desirable body weight as maintain desirable body weight as compared to those 20%+ abovecompared to those 20%+ above
Benefits of Risk Factor Benefits of Risk Factor ReductionReduction 45% lower risk for those who 45% lower risk for those who
maintain an active lifestyle maintain an active lifestyle compared with a sedentary compared with a sedentary lifestylelifestyle
35% lower risk in aspirin users 35% lower risk in aspirin users compared with nonuserscompared with nonusers
Coronary Heart Disease Coronary Heart Disease (CHD) or Coronary Artery (CHD) or Coronary Artery Disease (CAD)Disease (CAD)
Coronary Heart Disease Coronary Heart Disease (CHD) or Coronary Artery (CHD) or Coronary Artery Disease (CAD)Disease (CAD) Disease involves impeded blood flow to Disease involves impeded blood flow to
the network of blood vessels surrounding the network of blood vessels surrounding and serving the heartand serving the heart
Major cause is atherosclerosis; structural Major cause is atherosclerosis; structural and compositional changes in the inner and compositional changes in the inner wall of the arterieswall of the arteries
Manifested in clinical end points of Manifested in clinical end points of myocardial infarction (MI) and sudden myocardial infarction (MI) and sudden deathdeath
Disease involves impeded blood flow to Disease involves impeded blood flow to the network of blood vessels surrounding the network of blood vessels surrounding and serving the heartand serving the heart
Major cause is atherosclerosis; structural Major cause is atherosclerosis; structural and compositional changes in the inner and compositional changes in the inner wall of the arterieswall of the arteries
Manifested in clinical end points of Manifested in clinical end points of myocardial infarction (MI) and sudden myocardial infarction (MI) and sudden deathdeath
Pathophysiology of Pathophysiology of AtherosclerosisAtherosclerosis Vessel lining is injured (often at Vessel lining is injured (often at
branch points) branch points) →→ Plaque is deposited to repair Plaque is deposited to repair
injured area injured area →→ Plaque thickens, incorporating Plaque thickens, incorporating
cholesterol, protein, muscle cells, cholesterol, protein, muscle cells, and calcium (rate depends partly and calcium (rate depends partly on level of LDL-C in the blood) on level of LDL-C in the blood) →→
Pathophysiology of Pathophysiology of Atherosclerosis (cont)Atherosclerosis (cont) Arteries harden and narrow as Arteries harden and narrow as
plaque builds, making them less plaque builds, making them less elastic elastic →→
Increasing pressure causes Increasing pressure causes further damage further damage →→
A clot or spasm closes the A clot or spasm closes the opening, causing a heart attackopening, causing a heart attack
Pathophysiology of Pathophysiology of AtherosclerosisAtherosclerosis Proliferation of smooth-muscle Proliferation of smooth-muscle
cells, macrophages, and cells, macrophages, and lymphocytes lymphocytes
Formation of smooth muscle cells Formation of smooth muscle cells into a connective tissue matrixinto a connective tissue matrix
Accumulation of lipid and Accumulation of lipid and cholesterol in the matrix around cholesterol in the matrix around the cellsthe cells
Endothelial Injury Endothelial Injury Caused byCaused by HypercholesterolemiaHypercholesterolemia Oxidized low-density lipoproteinOxidized low-density lipoprotein HypertensionHypertension Cigarette smokingCigarette smoking DiabetesDiabetes ObesityObesity HomocysteineHomocysteine Diets high in saturated fat and cholesterolDiets high in saturated fat and cholesterol
Natural Progression of Natural Progression of AtherosclerosisAtherosclerosisNatural Progression of Natural Progression of AtherosclerosisAtherosclerosis
(From Harkreader H. Fundamentals. Philadelphia: W.B. Saunders, 2000)
Plaque or AtheromaPlaque or Atheroma
Lipid deposits and other materials Lipid deposits and other materials (cellular waste products, calcium, (cellular waste products, calcium, fibrin) that build up in the intimal fibrin) that build up in the intimal layerlayer
Heart Attack Heart Attack (Myocardial Infarction)(Myocardial Infarction)
Heart Attack Heart Attack (Myocardial Infarction)(Myocardial Infarction) When blood supply to the heart is When blood supply to the heart is
disrupted, the heart is damageddisrupted, the heart is damaged May cause the heart to beat May cause the heart to beat
irregularly or stop altogetherirregularly or stop altogether 25% of people do not survive 25% of people do not survive
their first heart attacktheir first heart attack
Symptoms of a Heart Symptoms of a Heart AttackAttack Intense, prolonged chest pain Intense, prolonged chest pain
or pressureor pressure Shortness of breathShortness of breath SweatingSweating Nausea and vomiting Nausea and vomiting
(especially women)(especially women) Dizziness (especially women)Dizziness (especially women) WeaknessWeakness Jaw, neck and shoulder pain Jaw, neck and shoulder pain
(especially women)(especially women) Irregular heartbeatIrregular heartbeat
Factors That May Bring Factors That May Bring On Heart Attack (in at-On Heart Attack (in at-risk)risk) DehydrationDehydration Emotional stressEmotional stress Strenuous physical activity when Strenuous physical activity when
not physically fitnot physically fit Waking during the night or Waking during the night or
getting up in the morninggetting up in the morning Eating a large, high-fat meal Eating a large, high-fat meal
(increases risk of clotting)(increases risk of clotting)
Cerebrovascular Cerebrovascular Accident (CVA) or Accident (CVA) or Brain AttackBrain Attack
Brain Attack (Stroke) Brain Attack (Stroke) or Cerebrovascular or Cerebrovascular Accident Accident
Symptoms of Stroke Symptoms of Stroke (Brain Attack)(Brain Attack) Sudden numbness or weakness of the Sudden numbness or weakness of the
face, arm or leg, especially on one side face, arm or leg, especially on one side of the body of the body
Sudden confusion, trouble speaking or Sudden confusion, trouble speaking or understanding understanding
Sudden trouble seeing in one or both Sudden trouble seeing in one or both eyes eyes
Sudden trouble walking, dizziness, loss Sudden trouble walking, dizziness, loss of balance or coordination of balance or coordination
Sudden severe headacheSudden severe headache
Functions of Functions of LipoproteinsLipoproteins Lipids are transported in the blood bound Lipids are transported in the blood bound
to proteinto protein Lipoproteins vary in composition, size, and Lipoproteins vary in composition, size, and
densitydensity Consist of varying amounts of triglyceride, Consist of varying amounts of triglyceride,
cholesterol, phospholipid, and proteincholesterol, phospholipid, and protein The ratio of protein to fat determines the The ratio of protein to fat determines the
density (HDLs have more protein than density (HDLs have more protein than LDLs)LDLs)
Lipoproteins combineLipoproteins combine
Lipids (triglycerides, Lipids (triglycerides, cholesterol)cholesterol)
ProteinProtein PhospholipidsPhospholipids
Functions of the Functions of the Plasma LipoproteinsPlasma Lipoproteins
Chylomicron—Transport of dietary Chylomicron—Transport of dietary triglyceridetriglyceride
VLDL—Transport of endogenous VLDL—Transport of endogenous triglyceridetriglyceride
IDL—LDL precursorIDL—LDL precursor LDL—Major cholesterol transport LDL—Major cholesterol transport
lipoproteinlipoprotein HDL—Reverse cholesterol transportHDL—Reverse cholesterol transport
Lipoprotein SummaryLipoprotein Summary
Lipoprotein Lipoprotein AssessmentAssessment Includes measurement of total Includes measurement of total
cholesterol, LDL cholesterol, HDL cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride level cholesterol, and triglyceride level after fastingafter fasting
Total CholesterolTotal Cholesterol
Captures cholesterol contained in all Captures cholesterol contained in all lipoprotein fractionslipoprotein fractions
60%-70% is carried on LDL60%-70% is carried on LDL 20%-30% is carried on HDL20%-30% is carried on HDL 10%-15% on VLDL10%-15% on VLDL
Total CholesterolTotal Cholesterol
Direct, positive association between TC Direct, positive association between TC and CHD riskand CHD risk
Diets high in saturated fats raise total Diets high in saturated fats raise total cholesterol and CHD incidence and cholesterol and CHD incidence and mortalitymortality
ATP-III Guidelines: lowering total ATP-III Guidelines: lowering total cholesterol and LDL-C reduces CHD riskcholesterol and LDL-C reduces CHD risk
10% reduction in TC decreases CHD risk 10% reduction in TC decreases CHD risk by about 30%by about 30%
Factors Affecting Total Factors Affecting Total CholesterolCholesterol AgeAge Diets high in fat, Diets high in fat,
saturated fat, saturated fat, cholesterolcholesterol
GeneticsGenetics Endogenous sex Endogenous sex
hormones (pre-hormones (pre-menopause)menopause)
Exogenous steroidsExogenous steroids
Drugs (beta Drugs (beta blockers, thiazide blockers, thiazide diuretics)diuretics)
Body weightBody weight Glucose toleranceGlucose tolerance Physical activityPhysical activity Season of the Season of the
yearyear DiseasesDiseases
Prevalence of High Prevalence of High Total CholesterolTotal Cholesterol Serum cholesterol levels in the U.S. Serum cholesterol levels in the U.S.
population have been declining since population have been declining since 19601960
More than half that decline occurred More than half that decline occurred between 1976 and 1991, when national between 1976 and 1991, when national preventive education efforts were begunpreventive education efforts were begun
Proportion of adults with TC>240 mg/dl Proportion of adults with TC>240 mg/dl fell from 27% to 19%, while HDL and fell from 27% to 19%, while HDL and VLDL remained unchangedVLDL remained unchanged
Total TriglyceridesTotal Triglycerides
Triglyceride-rich lipoproteins Triglyceride-rich lipoproteins include chylomicrons, VLDL, include chylomicrons, VLDL, remnants or intermediary productsremnants or intermediary products
Are atherogenicAre atherogenic At very high levels, At very high levels, ↑ risk of ↑ risk of
pancreatitispancreatitis Can be evidence of metabolic Can be evidence of metabolic
syndromesyndrome
ChylomicronsChylomicrons
Largest particlesLargest particles Transport dietary fat and cholesterol Transport dietary fat and cholesterol
from the small intestine to the liverfrom the small intestine to the liver In the bloodstream, triglycerides are In the bloodstream, triglycerides are
hydrolyzed by lipoprotein lipase (LPL) hydrolyzed by lipoprotein lipase (LPL) in muscle and adipose tissuein muscle and adipose tissue
When 90% of triglyceride is When 90% of triglyceride is hydrolyzed, released into blood as a hydrolyzed, released into blood as a remnantremnant
Liver metabolizes remnants, but some Liver metabolizes remnants, but some deliver cholesterol to the arterial walldeliver cholesterol to the arterial wall
Absent in fasting studiesAbsent in fasting studies
Very-Low-Density-Very-Low-Density-LipoproteinsLipoproteins Manufactured in the liver to transport Manufactured in the liver to transport
endogenous triglyceride and endogenous triglyceride and cholesterolcholesterol
60% is triglyceride60% is triglyceride Large VLDL may be nonatherogenicLarge VLDL may be nonatherogenic VLDL remnants or IDL appear to be VLDL remnants or IDL appear to be
atherogenicatherogenic Not routinely measured, but TG in Not routinely measured, but TG in
them is measured in total triglyceridethem is measured in total triglyceride
Intermediate-Density Intermediate-Density LipoproteinLipoprotein Formed with catabolism of VLDL, a Formed with catabolism of VLDL, a
precursor of LDLprecursor of LDL Rich in cholesterol and apo ERich in cholesterol and apo E High concentrations of IDL and VLDL High concentrations of IDL and VLDL
remnants directly related to lesion remnants directly related to lesion progression and coronary eventsprogression and coronary events
Not routinely measured, though Not routinely measured, though components can becomponents can be
Low-Density Low-Density LipoproteinLipoprotein Primary cholesterol carrier in bloodPrimary cholesterol carrier in blood Total cholesterol and LDL-cholesterol Total cholesterol and LDL-cholesterol
are strongly correlatedare strongly correlated 95% of apolipoproteins in LDL are apo-95% of apolipoproteins in LDL are apo-
B-100B-100 LDL is formed in VLDL catabolism, 60% LDL is formed in VLDL catabolism, 60%
is taken up by LDL receptors in liver, is taken up by LDL receptors in liver, adrenals, other tissues; rest is adrenals, other tissues; rest is metabolized via alternative pathwaysmetabolized via alternative pathways
Number and activity of receptors Number and activity of receptors determines LDL cholesterol levels in determines LDL cholesterol levels in the bloodthe blood
LDL-CLDL-C
Particles heterogeneous in size, density, Particles heterogeneous in size, density, lipid componentslipid components
Phenotype A: large particles, not Phenotype A: large particles, not associated with disease riskassociated with disease risk
Phenotype B typified by small, dense LDL Phenotype B typified by small, dense LDL particles; triglyceride rich, cholesterol particles; triglyceride rich, cholesterol depleted; predictive of depleted; predictive of
CHD risk in men and womenCHD risk in men and women
High Density High Density Lipoproteins (HDL)Lipoproteins (HDL)
Contain more protein than Contain more protein than the other lipoproteinsthe other lipoproteins
Apo A-1 is involved in Apo A-1 is involved in tissue cholesterol removaltissue cholesterol removal
High HDL is associated with High HDL is associated with low levels of chylomicrons, low levels of chylomicrons, VLDL remnants, and small, VLDL remnants, and small, dense LDLdense LDL
Lipoprotein ProfileLipoprotein Profile
Measures total cholesterol, LDL-Measures total cholesterol, LDL-cholesterol, HDL-cholesterol, and cholesterol, HDL-cholesterol, and triglycerides triglycerides
8-12 hour fast allows 8-12 hour fast allows chylomicrons to clearchylomicrons to clear
Friedenwald formula for Friedenwald formula for calculating LDL-C = (TC) – (HDL-C) calculating LDL-C = (TC) – (HDL-C) – (TG/5)– (TG/5)
ATP III GuidelinesATP III Guidelines
Adult Treatment Panel for the Adult Treatment Panel for the Detection, Evaluation, and Treatment Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults of High Blood Cholesterol in Adults convened by the National Heart, convened by the National Heart, Lung & Blood Institute of the NIHLung & Blood Institute of the NIH
Published 2002Published 2002 Updated in 2004Updated in 2004 Next revision expected in 2009 Next revision expected in 2009
(panel convened 2/08)(panel convened 2/08)
Lipoprotein ProfileLipoprotein Profile
If nonfasting, can measure total If nonfasting, can measure total and HDL cholesteroland HDL cholesterol
If TC>200 mg/dl or HDL-C is <40 If TC>200 mg/dl or HDL-C is <40 mg/dl, get fasting analysismg/dl, get fasting analysis
Evaluating Blood Evaluating Blood Lipids: Total Lipids: Total CholesterolCholesterol<200 mg/dL<200 mg/dL DesirableDesirable
200-239 200-239 mg/dLmg/dL
Borderline highBorderline high
≥≥240 mg/dL240 mg/dL HighHigh
Source: ATP-III Guidelines, NHLBI, accessed 2-2005
Evaluating Blood Evaluating Blood Lipids: TriglyceridesLipids: Triglycerides
<150 mg/dL<150 mg/dL NormalNormal
150-199150-199 Borderline highBorderline high
200-499200-499 HighHigh
>>500 mg/dl500 mg/dl Very highVery high
Source: ATP-III Guidelines, NHLBI, accessed 4-2005
Evaluating Blood Evaluating Blood Lipids: LDLLipids: LDL
<100 mg/dL<100 mg/dL OptimalOptimal
100-129100-129 Near optimalNear optimal
130-159130-159 Borderline highBorderline high
160-189160-189 HighHigh
≥≥190190 Very highVery high
Source: ATP-III Guidelines, NHLBI, accessed 2-2005
Evaluating Blood Evaluating Blood Lipids: HDLLipids: HDL
< 40 mg/dL< 40 mg/dL LowLow
≥ ≥ 60 mg/dL60 mg/dL HighHigh
Source: ATP-III Guidelines, NHLBI, accessed 2-2005
Risk Factors affect Risk Factors affect Lipid TargetsLipid Targets
Major, independent risk factorsMajor, independent risk factors Life-habit risk factorsLife-habit risk factors Emerging risk factorsEmerging risk factors
Major Risk Factors That Major Risk Factors That Modify LDL GoalsModify LDL Goals
Cigarette smokingCigarette smoking Hypertension (BP Hypertension (BP 140/90 mmHg or 140/90 mmHg or
on on antihypertensive medication)antihypertensive medication)
Low HDL cholesterol (<40 mg/dL)Low HDL cholesterol (<40 mg/dL)†† Family history of premature CHDFamily history of premature CHD
– CHD in male first degree relative <55 CHD in male first degree relative <55 – CHD in female first degree relative <65 CHD in female first degree relative <65 – Age (men Age (men 45 years; women 45 years; women 55 55
years)years)†
Life-Habit Risk FactorsLife-Habit Risk Factors
Obesity (BMI Obesity (BMI 30) 30) Physical inactivityPhysical inactivity Atherogenic dietAtherogenic diet
Emerging Risk FactorsEmerging Risk Factors
Lipoprotein (a)Lipoprotein (a) HomocysteineHomocysteine Prothrombotic factorsProthrombotic factors Proinflammatory factorsProinflammatory factors Impaired fasting glucose Impaired fasting glucose Subclinical atherosclerosisSubclinical atherosclerosis
Risk AssessmentRisk Assessment
Count major risk factors*Count major risk factors*
For patients with multiple (2+) risk factorsFor patients with multiple (2+) risk factors– Perform 10-year risk assessmentPerform 10-year risk assessment
For patients with 0–1 risk factorFor patients with 0–1 risk factor– 10 year risk assessment not required10 year risk assessment not required– Most patients have 10-year risk <10%Most patients have 10-year risk <10%
*HDL cholesterol *HDL cholesterol 60 mg/dL counts as a “negative” risk 60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total factor; its presence removes one risk factor from the total count.count.
CHD Risk EquivalentsCHD Risk Equivalents
Risk for major coronary events Risk for major coronary events equal to that in established CHDequal to that in established CHD
10-year risk for hard CHD >20%10-year risk for hard CHD >20%
Hard CHD = myocardial infarction + coronary death
DiabetesDiabetes
In ATP III, diabetes is In ATP III, diabetes is regarded regarded as a CHD risk equivalent. as a CHD risk equivalent.
Diabetes as a CHD Risk Diabetes as a CHD Risk EquivalentEquivalent
10-year risk for CHD 10-year risk for CHD 20% 20% High mortality with established High mortality with established
CHDCHD– High mortality with acute MIHigh mortality with acute MI– High mortality post acute MIHigh mortality post acute MI
CHD Risk EquivalentsCHD Risk Equivalents
Other clinical forms of Other clinical forms of atherosclerotic disease (peripheral atherosclerotic disease (peripheral arterial disease, abdominal aortic arterial disease, abdominal aortic aneurysm, and symptomatic aneurysm, and symptomatic carotid artery disease)carotid artery disease)
DiabetesDiabetes Multiple risk factors that confer a Multiple risk factors that confer a
10-year risk for CHD >20%10-year risk for CHD >20%
Calculate Your 10-Year Calculate Your 10-Year Risk of Heart AttackRisk of Heart Attack Risk Calculation Risk Calculation
http://hp2010.nhlbihin.net/atpiii/chttp://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=pubalculator.asp?usertype=pub
At-A-Glance treatment guidelines: At-A-Glance treatment guidelines: http://www.nhlbi.nih.gov/guidelinehttp://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.htms/cholesterol/atglance.htm
Risk CategoryRisk Category
CHD and CHD riskCHD and CHD riskequivalentsequivalents
Multiple (2+) risk Multiple (2+) risk factorsfactors
Zero to one risk Zero to one risk factorfactor
LDL Goal LDL Goal (mg/dL)(mg/dL)
<100<100
<130<130
<160<160
Three Categories of Three Categories of Risk that Modify LDL-C Risk that Modify LDL-C GOALSGOALS
ATP III GuidelinesATP III Guidelines
Goals and TreatmentGoals and TreatmentOverviewOverview
Primary Prevention Primary Prevention With With LDL-Lowering TherapyLDL-Lowering TherapyPublic Health ApproachPublic Health Approach
Reduced intakes of saturated fat Reduced intakes of saturated fat and cholesteroland cholesterol
Increased physical activityIncreased physical activity Weight controlWeight control
Causes of Secondary Causes of Secondary DyslipidemiaDyslipidemia
DiabetesDiabetes HypothyroidismHypothyroidism Obstructive liver diseaseObstructive liver disease Chronic renal failureChronic renal failure Drugs that raise LDL cholesterol Drugs that raise LDL cholesterol
and lower HDL cholesterol and lower HDL cholesterol (progestins, anabolic steroids, and (progestins, anabolic steroids, and corticosteroids)corticosteroids)
Secondary Prevention Secondary Prevention W/ W/ LDL-Lowering TherapyLDL-Lowering Therapy
Benefits: reduction in total mortality, Benefits: reduction in total mortality, coronary mortality, major coronary coronary mortality, major coronary events, coronary procedures, and events, coronary procedures, and strokestroke
LDL cholesterol goal: <100 mg/dLLDL cholesterol goal: <100 mg/dL Includes CHD risk equivalentsIncludes CHD risk equivalents Consider initiation of therapy during Consider initiation of therapy during
hospitalizationhospitalization(if LDL (if LDL 100 mg/dL)100 mg/dL)
LDL-C Goals in Different Risk LDL-C Goals in Different Risk CategoriesCategories
Risk CategoryRisk Category LDL GoalLDL Goal(mg/dL)(mg/dL)
LDL for Total LDL for Total Lifestyle Lifestyle
Change (TLC) Change (TLC) (mg/dL)(mg/dL)
LDL for LDL for Drug Therapy Drug Therapy
(mg/dL)(mg/dL)
CHD or CHD CHD or CHD Risk Risk
EquivalentsEquivalents(10-year risk (10-year risk
>20%)>20%)
<100; <100; optional optional goal <70 goal <70
mg/dLmg/dL
100100
100 100 ((<<100: 100:
consider drug consider drug optionsoptions
Moderately Moderately high riskhigh risk
2+ Risk 2+ Risk Factors Factors
(10-year risk (10-year risk 10-20%)10-20%)
<130<130 130130
>130 mg/dL >130 mg/dL (100-129 (100-129 mg/dL, mg/dL,
consider drug consider drug options)options)
ATP-3 update, Circulation, 2004
LDL-C Goals in LDL-C Goals in Different Risk Different Risk CategoriesCategories
Risk CategoryRisk Category LDL GoalLDL Goal(mg/dL)(mg/dL)
LDL for Total LDL for Total Lifestyle Lifestyle
Change (TLC) Change (TLC) (mg/dL)(mg/dL)
LDL for LDL for Drug Therapy Drug Therapy
(mg/dL)(mg/dL)
Moderate risk: Moderate risk: 2+ risk factors 2+ risk factors (10 year (10 year risk<10%)risk<10%)
<130 mg/dL<130 mg/dL >>130 mg/dL130 mg/dL >>160 mg/dL160 mg/dL
Lower risk (0-Lower risk (0-1 risk factors)1 risk factors)
<160 mg/dL<160 mg/dL >>160 mg/dL160 mg/dL >>190 mg/dL 190 mg/dL (160-189 (160-189 mg/dL, drug mg/dL, drug optional)optional)
ATP-3 update, Circulation, 2004