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