Cholesterol Guidelines 2013

10-year Hard ASCVD risk for Persons Aged 40 - 75

	White	African American
Female
Male
Not used in model:
Triglycerides	mg/dL
Diastolic BP	mm Hg
non-HDL cholesterol: ***** mg/dL Estimated LDL cholesterol: ***** mg/dL
Height (inches):		Weight (lb):
Glucose	mg/dL
HbA1c	%

Age	yr
Total Cholesterol	mg/dL
HDL Cholesterol	mg/dL
Antihypertensive treatment?
Systolic BP	mm Hg
Current Smoker?
Diabetes?

*****

Hard ASCVD risk is defined as defined as first occurrence nonfatal and fatal MI, and nonfatal and fatal stroke

Algorithm is from Appendix 4 of:
2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol. 2013;():. doi:10.1016/j.jacc.2013.11.005
Available on the Web at: http://content.onlinejacc.org/article.aspx?articleid=1770220

Framingham 10-year risk

Algorithm is from page 3230-1 of:
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) final report.
Circulation. 2002 Dec 17;106(25):3143-421.
Available on the Web at: http://circ.ahajournals.org/content/106/25/3143.long

ATP III LDL Goal recommendation

Recommendation is from Table IV-1 of:
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) final report.
Circulation. 2002 Dec 17;106(25):3143-421.
Available on the Web at: http://circ.ahajournals.org/content/106/25/3143.long

Lifetime risk

Atherosclerotic CVD events are defined as the occurrence of myocardial infarction, coronary insufficiency, death resulting from coronary heart disease, angina pectoris, atherothrombotic stroke, intermittent claudication, or other cardiovascular death.

Data from:
Lloyd-Jones, DM, Leip EP, et al. Prediction of Lifetime Risk for Cardiovascular Disease by Risk Factor Burden at 50 Years of Age. Circulation. 2006; 113: 791-798. doi: 10.1161/CIRCULATIONAHA.105.548206.
Available on the web at: http://circ.ahajournals.org/content/113/6/791

These tools have not been officially
sanctioned or approved by the
Use at own risk.

Parameter	ln(age)	ln²(age)	ln(TC)	ln(age) x ln(TC)	ln(HDL)	ln(age) x ln(HDL)	log(SBP) (treated)	log(age) x log(SBP) (treated)	log(SBP) (untreated)	log(age) x log(SBP) (untreated)	Current Smoker	log(age) x current smoker	Diabetes
Parameter Coefficient
Calculated Value
Coefficient x Value

Sum of products
Mean sum of products
Baseline Survival

Major Recommendations for Statin Therapy

	LDL < 70	LDL 70-189			LDL ≥ 190
Age 21-39	Clinical ASCVD: High-intensity statin				High-intensity statin
Age 40-75	Clinical ASCVD: High-intensity statin	Clinical ASCVD: High-intensity statin
			No DM	DM
		10-y risk ≤ 7.5%	Recalculate risk 4 - 6 years	Moderate-intensity statin
		10-y risk > 7.5%	Moderate- or High- intensity statin	High-intensity statin
Age > 75	Clinical ASCVD: Moderate-intensity statin
Clinical ASCVD includes acute coronary syndromes, history of MI, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin.

High-Intensity Statin Therapy	Moderate-Intensity Statin Therapy	Low-Intensity Statin Therapy
Daily dose lowers LDL-C on average, by approximately ≥ 50%	Daily dose lowers LDL-C on average, by approximately 30% to 50%	Daily dose lowers LDL-C on average, by < 30%
Atorvastatin (40) 80 mg Rosuvastatin 20 (40) mg	Atorvastatin 10 (20) mg Rosuvastatin (5) 10 mg Simvastatin 20-40 mg Pravastatin 40 (80) mg Lovastatin 40 mg Fluvastatin 40 mg bid Fluvastatin XL 80 mg Pitavastatin 2 - 4 mg	Pravastatin 10-20 mg Lovastatin 20 mg Simvastatin 10 mg Fluvastatin 20 - 40 mg Pitavastatin 1 mg
Statins and doses that are approved by the U.S. FDA but were not tested in the clinical trials reviewed are listed in italics

From Figure 2 and Table 5 of:
2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
Circulation. 2013;01.cir.0000437738.63853.7a
Published online before print November 12 2013, doi:10.1161/01.cir.0000437738.63853.7a
Available on the Web at: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.citation

ATP III Guidelines

Clinical CHD Symptomatic carotid artery disease Peripheral arterial disease Abdominal aortic aneurysm Diabetes
Step 1: Determine lipoprotein levels - obtain complete lipoprotein profile after 9- to 12-hour fast.
Step 2: Identify presence of clinical atherosclerotic disease that confers high risk for coronary heart disease (CHD) events (CHD risk equivalent)
Step 3: Determine presence of major risk factors (other than LDL)
Smoking
Hypertension
HDL
Family history of premature CHD*
Age
Total major risk factors
Step 4: If 2+ risk factors (other than LDL) are present without CHD or CHD risk equivalent, assess 10-year (short-term) CHD risk
10-year CHD Risk % (Framingham)


Step 5: Determine Risk Category
Risk Category	hah
LDL Goal	hah
LDL Level at which to Initiate Therapeutic Lifestyle Changes	hah
LDL Level at which to Consider Drug Therapy	heh
non-HDL goal
* Some authorities recommend use of LDL-lowering drugs in this category if an LDL cholesterol <100 mg/dL cannot be achieved by therapeutic lifestyle changes. Others prefer use of drugs that primarily modify triglcerides and HDL, e.g., nicotinic acid or a fibrate. Clinical judgement may also call for deferring drug therapy in this subcategory

Step 6: Initiate therapeutic lifestyle changes (TLC) if LDL is above goal.

TLC Diet:
Saturated fat <7% of calories, cholesterol <200 mg/day
Consider increased viscous (soluble) fiber (10-25 g/day) and plant stanols/sterols (2g/day) as therapeutic options to enhance LDL lowering
Weight management
Increased physical activity

Drug Class	Agents and Daily Doses	Lipid/Lipoprotein Effects	Side Effects	Contraindications
Step 7: Consider adding drug therapy if LDL exceeds levels shown in Step 5 table
HMG CoA reductase inhibitors (statins)	Lovastatin (20-80 mg) Pravastatin (20-40 mg) Simvastatin (20-80 mg) Fluvastatin (20-80 mg) Atorvastatin (10-80 mg) Cerivastatin (0.4-0.8 mg) See current statin recommendations above	LDL ↓ 18-55% HDL ↑ 5-15% TG ↓ 7-30%	Myopathy Increased liver enzymes	Absolute: Active or chronic liver disease Relative: Concomitant use of certain drugs*
Bile acid sequestrants	Cholestyramine (4-16 g) Colestipol (5-20 g) Colesevelam (2.6-3.8 g)	LDL ↓ 15-30% HDL ↑ 3-5% TG No change or increase	Gastrointestinal distress Constipation Decreased absorption of other drugs	Absolute: dysbetalipoproteinemia TG >400 mg/dL Relative: TG >200 mg/dL
Nicotinic acid	Immediate release (crystalline) nicotinic acid (1.5-3 gm) Extended release nicotinic acid(Niaspan) (1-2 g) Sustained release nicotinic acid (1-2 g)	LDL ↓ 5-25% HDL ↑ 15-35% TG ↓ 20-50%	Flushing Hyperglycemia Hyperuricemia (or gout) Upper GI distress Hepatotoxicity	Absolute: Chronic liver disease Severe gout Relative: Diabetes Hyperuricemia Peptic ulcer disease
Fibric acids	Gemfibrozil (600 mg BID) Fenofibrate (200 mg) Clofibrate (1000 mg BID)	LDL ↓ 5-20%(may be increased inpatients with high TG) HDL ↑ 10-20% TG ↓ 20-50%	Dyspepsia Gallstones Myopathy	Absolute: Severe renal disease Severe hepatic disease

Risk factor	Defining level
Step 8: Identify metabolic syndrome and treat, if present, after 3 months of TLC.
Abdominal obesity	Waist circumference: M: > 102 cm (40 in) F: > 88 cm (35 in)
Triglycerides	≥ 150 mg/dL
HDL Cholesterol	M: < 40 mg/dL F: < 50 mg/dL
Blood Pressure	≥ 130 / ≥ 85 mm Hg
Fasting Glucose	≥ 110 mg/dL

Treatment of the metabolic syndrome

Treat underlying causes
Intensify weight management
Increase physical activity
Treat lipid and non-lipid risk factors if they persist despite these lifestyle changes
Treat hypertension
Use aspirin for CHD patients to reduce prothrombotic state
Treat elevated triglycerides and or low HDL (as shown in Step 9)

Step 9: treat elevated triglycerides
ATP III Serum Triglyceride Class:

Primary aim of therapy is to reach LDL goal
Intensify weight management
Increase physical activity

Triglycerides 200-499 mg/dL and LDL goal reached	Set secondary goal for non-HDL cholesterol 30 mg/dL higher than LDL goal Intensify therapy with LDL-lowering drug, or Add nicotinic acid or fibrate to further lower VLDL
Triglycerides ≥ 500 mg/dL	First lower triglycerides to prevent pancreatitis Very-low-fat diet (≤ 15% of calories from fat) Weight management and physical activity Fibrate or nicotinic acid When triglycerides < 500 mg/dL, commence LDL-lowering therapy

Treatment of low HDL cholesterol (≤ 40 mg/dL)

First reach LDL goal, then:
Intensify weight management and increase physical activity
If triglycerides 200-499 mg/dL, achieve non-HDL goal
If triglycerides < 200 mg/dL (isolated low HDL) in CHD/CHD equivalent, consider nicotinc acid or fibrate

LDL Estimation from standard lipid profile

TG, mg/dL	Non-HDL-C, mg/dL
TG, mg/dL	<100	100-129	130-159	160-189	190-219	>219
7 - 49	3.5	3.4	3.3	3.3	3.2	3.1
50 - 56	4.0	3.9	3.7	3.6	3.6	3.4
57 - 61	4.3	4.1	4.0	3.9	3.8	3.6
62 - 66	4.5	4.3	4.1	4.0	3.9	3.9
67 - 71	4.7	4.4	4.3	4.2	4.1	3.9
72 - 75	4.8	4.6	4.4	4.2	4.2	4.1
76 - 79	4.9	4.6	4.5	4.3	4.3	4.2
80 - 83	5.0	4.8	4.6	4.4	4.3	4.2
84 - 87	5.1	4.8	4.6	4.5	4.4	4.3
88 - 92	5.2	4.9	4.7	4.6	4.4	4.3
93 - 96	5.3	5.0	4.8	4.7	4.5	4.4
97 - 100	5.4	5.1	4.8	4.7	4.5	4.3
101 - 105	5.5	5.2	5.0	4.7	4.6	4.5
106 - 110	5.6	5.3	5.0	4.8	4.6	4.5
111 - 115	5.7	5.4	5.1	4.9	4.7	4.5
116 - 120	5.8	5.5	5.2	5.0	4.8	4.6
121 - 126	6.0	5.5	5.3	5.0	4.8	4.6
127 - 132	6.1	5.7	5.3	5.1	4.9	4.7
133 - 138	6.2	5.8	5.4	5.2	5.0	4.7
139 - 146	6.3	5.9	5.6	5.3	5.0	4.8
147 - 154	6.5	6.0	5.7	5.4	5.1	4.8
155 - 163	6.7	6.2	5.8	5.4	5.2	4.9
164 - 173	6.8	6.3	5.9	5.5	5.3	5.0
174 - 185	7.0	6.5	6.0	5.7	5.4	5.1
186 - 201	7.3	6.7	6.2	5.8	5.5	5.2
202 - 220	7.6	6.9	6.4	6.0	5.6	5.3
221 - 247	8.0	7.2	6.6	6.2	5.9	5.4
248 - 292	8.5	7.6	7.0	6.5	6.1	5.6
293 - 399	9.5	8.3	7.5	7.0	6.5	5.9
400 - 13975	11.9	10.0	8.8	8.1	7.5	6.7

*****

From Figure 2 of:
Martin SS, Blaha MJ, Elshazly MB, et al. Comparison of a Novel Method vs the Friedewald Equation for Estimating Low-Density Lipoprotein Cholesterol Levels From the Standard Lipid Profile.
JAMA. 2013;310(19):2061-2068. doi:10.1001/jama.2013.280532.
Not available on the Web without forking over $$.

Online CV Risk Calculation Tool