Cardiovascular disease (CVD) is a major cause of morbidity and mortality in the U.S.

Risk factors for CVD

• Elevated low density lipoprotein (LDL) cholesterol
• Tobacco smoking
• Hypertension (140/90 mmHg or on medication for hypertension)
• Low high density lipoprotein (HDL) cholesterol <40 mg/dL
• Family history of premature CVD (CVD in first degree male relative <55 years old; CVD in first female degree relative <65 years old)
• Aging
• Refer to Cardiovascular Disease (Traditional Risk Markers) topic at www.arupconsult. com for the National Heart Lung and Blood Institute Guidelines

Basis of risk assessment

• Statins have been demonstrated to reduce LDL concentrations and reduce cardiovascular mortality in numerous trials
• Determination of which patients benefit from drug therapy is important for early prevention and intervention
• Adult Treatment Panel (ATP) III guidelines (Framingham Study)
  • Identify patients at risk for development of CVD
  • Develop plan of action for at risk patients with target goals for LDL and triglycerides (TG)

Diagnosis and Treatment

Risk Assessment

• ATP III Recommendations (for adults >20 years old, obtain baseline lipid testing and repeat testing every 5 years)
  • Determine lipoprotein concentrations using fasting lipid testing (LDL-C, HDL and TG are the minimum recommendation)
  • Identify risk factors present for CVD
    • Elevated low density lipoprotein (LDL) cholesterol
    • Tobacco smoking
    • Hypertension (blood pressure greater than or equal to 140/90 mmHg or on medication for hypertension)
    • Low high density lipoprotein (HDL) cholesterol (<40 mg/dL)
      • HDL cholesterol greater than or equal to 60 mg/dL counts as a negative risk factor; its presence removes one risk factor from the total count
    • Family history of premature CVD (CVD in first degree male relative <55 years old; CVD in first degree female relative <65 years old)
    • Aging (men greater than or equal to 45 years; women greater than or equal to 55 years)
  • If >2 risk factors are present, assess Framingham projections for 10 year CVD risk
    • 20% 10 year risk by Framingham criteria is considered a CVD equivalent risk factor
    • Refer to Cardiovascular Disease (Traditional Risk Markers) topic at www.arupconsult. com for the Risk Assessment Tool for Estimating 10-year Risk of Developing Hard CVD
  • Refer to Cardiovascular Disease (Traditional Risk Markers) topic at www.arupconsult. com for additional information on the ATP III Guidelines and Framingham assessment
• Determine final risk category for treatment goals
  • High risk - patients with CVD or CVD equivalent (diabetes or >20% 10 year risk)
    • Target LDL-C is <100 mg/dL (optional <70mg/dL)
  • Intermediate risk - patients with 2 or more risk factors and 10 year risk <20%
    • Target LDL-C is <130 mg/dL
  • Low risk  - patients with fewer than 2 risks are low risk
    • Target LDL-C is <160 mg/d
• Initiate lifestyle modifications and/or drug therapy to reduce LDL-C to target concentrations
• High TG (>150 mg/dL)
  • Lifestyle modifications
  • If TG greater than or equal to 200 mg/dL, non-HDL-C target is 30 mg/dL higher than LDL-C target

Disease Monitoring

• If LDL-C remains elevated after 3 months of therapy or recommended diet and exercise modifications, assess for presence of metabolic syndrome (ATP III guidelines)
  • Criteria for metabolic syndrome  - waist circumference >40 inches (male), >35 inches (female); TG greater than or equal to 150 mg/dL; HDL-C <40 mg/dL (male), <50 mg/dL (female); fasting glucose greater than or equal to 100 mg/dL
  • If the patient meets criteria for metabolic syndrome, consider LDL-C target concentration <100 mg/dL