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  • Cholesterol Guidelines for People with High Risk of Heart Attack

    Image for cholesterol article The National Cholesterol Education Program (NCEP) offers cholesterol guidelines for men and women.

    Cholesterol and Heart Disease

    High levels of LDL cholesterol 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, and 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 angina (chest pain), history of coronary artery procedures, evidence of clogged arteries (myocardial ischemia), diabetes, metabolic syndrome, high LDL cholesterol, low HDL cholesterol, high blood pressure, smoking, family history of heart disease, and age.
    There are three 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 ten years)
    • Moderate risk (less than 10% chance of heart attack within ten years, but still with two or more risk factors)
    • Lower risk (a person with one or fewer risk factors)
    NCEP's recommendations include:
    Risk Category Drug Therapy Based on LDL levels
    High risk
    • If equal to or above 100 mg/dL (2.6 mmol/L)
    • Optional between 70-100 mg/dL (1.8-2.6 mmol/L) if very high risk
    Moderately high risk
    • If above 130 mg/dL (3.4 mmol/L)
    • Optional between 100-129 mg/dL (2.6-3.3 mmol/L)
    Moderate risk
    • If equal to or above 160 mg/dL (4.2 mmol/L)
    Lower risk
    • If equal to or above 190 mg/dL (4.9 mmol/L) after lifestyle changes
    • Optional if 160-189 mg/dL (4.2-4.9 mmol/L) after lifestyle changes
    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.

    Recommended Treatment

    Lifestyle Therapy

    NCEP recommends the following lifestyle changes:
    • 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 (eg, whole grains, vegetables, fruits, nuts, and seeds)
    • Maintaining a healthy weight
    • Getting regular physical activity
    Diet and exercise remain the first-line treatment option for high cholesterol in those at low to moderate risk for heart disease. And, most certainly, they are measures of prevention that everyone should heed.
    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.

    Drug Therapy

    Statins are often prescribed for high cholesterol. They are designed to be used in combination with lifestyle therapy. Statins works by blocking an enzyme (HMG-CoA reductase) that helps the body make cholesterol. The benefit from these medicines may also come from their anti-inflammation properties. Common examples of statins include:
    • Atorvastatin
    • Lovastatin
    • Simvastatin
    • Pravastatin
    • Rosuvastatin
    Statin drugs have proven to be effective in reducing cholesterol levels. These medicines may also reduce the incidence of heart attack, stroke, and death.


    American Heart Association http://www.americanheart.org/

    National Heart, Lung and Blood Institute http://www.nhlbi.nih.gov/


    Health Canada http://www.hc-sc.gc.ca/

    Heart and Stroke Foundation of Canada http://www.heartandstroke.com/


    American College of Cardiology/American Heart Association. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. J Am Coll Cardiol. 2013: early online. Available at: http://content.onlinejacc.org/article.aspx?articleID=1770217. Accessed January 6, 2013.

    Cardiovascular disease prevention overview. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/ . Updated September 9, 2012. Accessed September 19, 2012.

    NCEP ATP III guidelines. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/. Accessed September 19, 2012.

    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 http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf. Accessed September 19, 2012.

    Screening for lipid disorders in adults: U.S. Preventive Services Task Force recommendation statement. National Guidelines Clearinghouse website. Available at: http://www.guideline.gov/summary/summary.aspx?doc%5Fid=12634#s23 . Published June 2008. Accessed September 19, 2012.

    Statins. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/. Updated September 3, 2012. Accessed September 19, 2012.

    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. Updated August 23, 2012. Accessed September 19, 2012.

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