Cholesterol Guidelines for People with High Risk of Heart Attack
The National Cholesterol Education Program (NCEP) offers cholesterol guidelines for men and women.
Cholesterol and Heart Disease
High levels of LDL
and/or low levels of high-density lipoprotein (HDL, or “good”) cholesterol, are major risk factors for heart attack and stroke, two of the most common causes of death in the US.
The good news is that most people can control major heart disease risk factors, including cholesterol levels, smoking, excessive weight, lack of exercise,
high blood pressure
type 2 diabetes
Screening for lipid disorders like high cholesterol depends on your age and whether you have any risk factors for heart disease.
A Run-Down of the Guidelines
The guidelines propose different recommendations depending on a person’s degree of risk of heart attack within the next ten years. This risk is determined by the presence of several risk factors, including history of heart attack or stroke, unstable or stable
(chest pain), history of coronary artery procedures, evidence of clogged arteries, diabetes, metabolic syndrome, high LDL cholesterol, low HDL cholesterol, high blood pressure, smoking, family history of heart disease, and age.
There are 4 major risk levels:
- High risk (over 20% chance of heart attack within ten years) including those with coronary heart disease (CHD) or those having a CHD risk equivalent—diabetes, peripheral arterial disease, abdominal aortic aneurysm, or carotid artery disease)
- Moderately high risk (10%-20% chance of heart attack within 10 years with 2 or more risk factors)
- Moderate risk (less than 10% chance of heart attack within 10 years, but still with 2 or more risk factors)
- Lower risk (a person with less than 10% chance of heart attack within 10 years and one or fewer risk factors)
||Drug Therapy Based on LDL levels
- Begin drug therapy along with lifestyle changes if LDL equal to or above 130 mg/dL (2.2 mmol/L)
- Drug therapy is optional if LDL between 100-129 mg/dL (1.7-2.2 mmol/L), but lifestyle changes should be started
- Drug therapy is not needed if LDL under 100 mg/dL (1.7 mmol/L), but lifestyle changes should be started
- Therapy should keep LDL level less than 100 mg/dL
|Moderately high risk
- Begin drug therapy if LDL equal to or above 130 mg/dL (2.2 mmol/L) and 3 months of lifestyle changes do not bring it below 130 mg/dL
- Drug therapy is not needed if LDL under 130 mg/dL or LDL goes below this with lifestyle changes for 3 months
- Therapy should keep LDL level less than 130 mg/dL
- Drug therapy is optional if LDL equal to or above 160 mg/dL (2.7 mmol/L), but lifestyle changes should be started
- Drug therapy is not needed if LDL under 130 mg/dL (2.2 mmol/L) or LDL goes below 160 mg/dL with lifestyle changes for 3 months
- Therapy should keep LDL level less than130 mg/dL
- Consider drug therapy along with lifestyle changes if LDL equal to or above 190 mg/dL (3.2 mmol/L)
- Drug therapy is optional if LDL 160-190 mg/dL (2.7-3.4 mmol/L) and 3 months of lifestyle changes do not bring it below 160 mg/dL
- Drug therapy is not needed if LDL under 160 mg/dL or LDL goes below this with lifestyle changes for 3 months
The guidelines also state that drug treatment for high-risk patients must be aggressive enough to achieve at least a 30%-40% reduction in LDL levels. In addition to drug therapy, NCEP stresses the importance of initiating therapeutic lifestyle changes in high-risk persons—regardless of cholesterol level—since lifestyle changes can reduce cardiovascular risk in several ways besides lowering cholesterol.
Diet and exercise remain the first-line treatment option for high cholesterol in those at low to moderate risk for heart disease. Most certainly, they are measures of prevention that everyone should heed. Lifestyle changes include:
- Eat a diet low in saturated fat and cholesterol.
- Eat plenty of plant based foods to get the beneficial sterols and stanols that they contain.
- Increase soluble fiber in your diet with whole grains, vegetables, fruits, nuts, and seeds.
- Quit smoking
- Maintain a healthy weight
- Get regular physical activity
If you are concerned about your cholesterol levels and your risk for heart disease, talk to your doctor. There are steps that you can take to reduce the risk.
Statins are often prescribed for high cholesterol. They are designed to be used in combination with lifestyle changes. Statins works by blocking an enzyme (HMG-CoA reductase) that helps the body make cholesterol. The benefit from these medications may also come from their anti-inflammation properties.
Statin drugs have proven to be effective in reducing cholesterol levels. These medications may also reduce the incidence of heart attack, stroke, and death.
American Heart Association
National Heart, Lung, and Blood Institute
Heart and Stroke Foundation of Canada
Cardiovascular disease prevention overview. EBSCO DynaMed Plus website. Available at:
http://www.dynamed.com/topics/dmp~AN~T116873/Cardiovascular-disease-prevention-overview. Updated June 29, 2017. Accessed July 31, 2017.
Montalescot G, Sechtem U, Achebach S, et al. 2013 European Society of Cardiology guidelines on the management
of stable coronary artery disease. Eur Heart J. 2013;34(38):2949-3003.
Statins. EBSCO DynaMed Plus website. Available at:
http://www.dynamed.com/topics/dmp~AN~T116844/Statins. Updated July 28, 2017. Accessed July 31, 2017.
Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Circulation. 2014;129(25 Suppl 2):S1-S45.
Third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults. National Heart, Lung, and Blood Institute. Available at: https://www.nhlbi.nih.gov/files/docs/guidelines/atp3xsum.pdf. Accessed July 31, 2017.
What your cholesterol levels mean. American Heart Association. Available at: http://www.heart.org/HEARTORG/Conditions/Cholesterol/AboutCholesterol/What-Your-Cholesterol-Levels-Mean%5FUCM%5F305562%5FArticle.jsp#.WYCAOYTytQI. Updated July 5, 2017. Accessed July 31, 2017.