Targets

In ATP-III the NCEP implemented these conceptual changes: (1) an optimal LDL-C is defined as less than 100 mg/dL for all patients independent of race or gender; (2) an HDL less than 40 mg/dL is now defined as a categorical risk factor for CAD; and (3) it defined target levels for non-HDL-C. Non-HDL-C is defined as total cholesterol minus HDL-C and is an estimate of atherogenic lipoproteins in serum (VLDL + LDL). The risk-stratified target for non-HDL-C is the LDL-C target plus 30 (see Table 27-1). LDL-C reduction is the primary goal of therapy in patients with dyslipidemia. However, in patients with fasting triglyceride (TG) levels greater than 200 mg/dL, non-HDL reduction is the secondary priority of therapy. There is currently no specified target for HDL-C elevation. However, in patients with low HDL-C, it is important to try to raise HDL-C as much as possible. According to a recent AHA Consensus Statement, an HDL-C less than 50 mg/dL in women is now considered low (Mosca et al., 2004). The American Diabetes Association (ADA) advocates

Table 27-2 Dietary Recommendations for Therapeutic Lifestyle Change

Dietary Component

Recommended Allowance

Polyunsaturated fat

Up to 10% of total calories

Monounsaturated fat

Up to 20% of total calories

Total fat

25%-35% of total calories

Carbohydrate

50%-60% of total calories

Dietary fiber

20-30 g/day

Protein

About 15% of total calories

Dietary cholesterol

<200 mg/day

HDL-C goals of 40 mg/dL or higher for men and 50 mg/dL or higher for women with diabetes mellitus.

Based on such trials as the Heart Protection Study (Heart Protection Study Collaborative Group, 2002), Treating to New Targets study (LaRosa et al., 2005), and the Pravastatin or Ator-vastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction trial (Cannon et al., 2004), in regard to LDL-C reduction and reducing risk for CAD-related morbidity and mortality, "the lower the better" (Toth, 2004). The NCEP "white paper" recommended that physicians consider treating LDL-C to less than 70 mg/dL and non-HDL-C to less than 100 mg/dL in very-high-risk patients (e.g., recent ACS, diabetic patient with multiple, poorly controlled risk factors) (Grundy et al., 2004). Other therapeutic options include initiating antilip-idemic medication with therapeutic lifestyle change if baseline LDL-C is greater than 100 mg/dL in patients with moderately high and high risk; in patients at high risk with baseline LDL-C less than 100 mg/dL, a further reduction of LDL-C by 30% to 40% with medication is a therapeutic option. AHA recommends LDL-C less than 70 mg/dL as a reasonable option for any patient with CAD (Smith et al., 2006).

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