Key Concepts

0 The risk of atherosclerosis is directly related to increasing levels of serum cholesterol.

01 The National Cholesterol Education Program Adult Treatment Panel III guidelines have set the "optimal" level for low-density lipoprotein (LDL) cholesterol for all adults as less than 100 mg/dL (2.59 mmol/L).

All adults greater than 20 years of age should be screened at least every 5 years using a fasting blood sample.

Ö1 The benefits of lowering LDL cholesterol to as low as 70 mg/dL (1.81 mmol/ L) have been demonstrated in clinical trials; however, the lowest level at which to treat LDL cholesterol where there are no further benefits in coronary heart disease (CHD) risk has not yet been determined.

An adequate trial oftherapeutic lifestyle changes (TLC) should be employed in all patients, but pharmacotherapy should be instituted concurrently in higher-risk patients.

Typically, statins are the medications ofchoice to treat high LDL cholesterol because of their ability to substantially reduce LDL cholesterol, ability to reduce morbidity and mortality from atherosclerotic disease, convenient once-daily dosing, and low risk of side effects.

Patients with metabolic syndrome have an additional lipid parameter that needs to be assessed, namely non-high-density lipoprotein (non-HDL) cholesterol (total cholesterol minus HDL cholesterol). The target for non-HDL cholesterol is less than the patient's LDL cholesterol target plus 30 mg/dL (0.78 mmol/L).

After assessment and control of LDL cholesterol, patients with serum triglycerides of 200 to 499 mg/dL (2.26-5.64 mmol/L) should be assessed for atherogenic dyslipidemia (low HDL cholesterol and increased small-dense LDL particles) and the metabolic syndrome.

Combination drug therapy is an effective means to achieve greater reductions in LDL cholesterol (statin + ezetimibe or bile acid resin, bile acid resin + ezetimibe, or three-drug combinations) as well as raising HDL cholesterol and lowering serum triglycerides (statin + niacin or fibrate).

© Reducing LDL cholesterol while substantially raising HDL cholesterol (statin + niacin) appears to reduce the risk ofatherosclerotic disease progression to a greater degree than statin monotherapy

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