Cholesterol is a fat-like substance that is present in cell membranes and is a building block for bile acids and natural steroid hormones. It travels in the blood and contains lipids (fats) and proteins (lipoproteins). There are 3 major classes of lipoproteins found in the blood and make up your total cholesterol level: low density lipoproteins (LDL), high density lipoproteins (HDL), and very low density lipoproteins (VLDL).¹

• LDL cholesterol makes up 60-70% of the total cholesterol and is atherogenic, or causes plaque to build up in arteries.
• HDL cholesterol makes up 20-30% of the total cholesterol and may protect against developing atherosclerosis.
• VLDL cholesterol is rich with triglycerides (another type of fat) and make up 10-15% of the total cholesterol.

Classification of LDL, Total, HDL cholesterol, and Triglycerides (mg/dL): ¹

Treatment of elevated cholesterol and triglyceride levels is dependent on your risk. People in the highest risk category are those with a coronary heart disease (CHD) event (heart attack, unstable angina) and those considered to be at the same risk as someone who has had a heart attack (CHD equivalent):

• Diabetes
• Clinical coronary heart disease (abnormal stress test, blocked arteries to the heart)
• Peripheral arterial disease (blocked arteries in arms and/or legs)
• Previous stroke or symptomatic carotid artery disease (blocked artery blood vessel leading to the head)
• Abdominal aortic aneurysm
• Framingham 10-year risk assessment score of > 20%

Treatment options:
1.  Therapeutic Lifestyle Changes (TLC):

• TLC diet with saturated fat < 7% of total calories and cholesterol intake < 200 mg/day
• Weight management
• Increased physical activity

2.  Medications to lower lipids:

• Statins (Lescol, Pravacol, Mevacor, Zocor, Lipitor, Crestor)
• Bile acid sequestrants (Questran, Colestid, WelCol)
• Nicotinic acid (Niaspan)
• Fibric acids (Lopid, Tricor, Atromid)
• “Intestinal Absorption Inhibitor” (Zetia)

Treatment Goals:

LDL cholesterol is the primary goal and treated first. Everyone with high LDL cholesterol levels will be treated with Therapeutic Lifestyle Changes. Your doctor will determine if and when to start medication.

*Framingham 10-year risk assessment score

People with high triglyceride levels and/or low HDL levels may need additional treatment after the LDL cholesterol goal is reached. Your doctor will consider your triglyceride and LDL and HDL cholesterol levels when choosing medication.

Revised Guidelines²
Since the Adult Treatment Panel III guidelines were released in 2001, 5 large clinical trials using cholesterol-lowering medications in the ‘statin’ family have been completed. In July 2004, the guidelines were revised because of the results of these clinical trials.

The guidelines now recommend the treatment option of setting the LDL cholesterol goal to < 70 mg/dL for people at very high risk for heart attack. People that are at very high risk include those with known cardiovascular disease plus:

• multiple risk factors (especially diabetes)
• severe and poorly controlled risk factors (especially continued cigarette smoking)
• multiple risk factors of metabolic syndrome (especially high triglycerides > 200 mg/dL plus non-HDL cholesterol > 130 mg/dL with low HDL cholesterol < 40 mg/dL)
• patients with acute coronary syndrome (heart attack or unstable angina)

The revised guidelines also recommend a treatment option of lowering the LDL cholesterol  to < 100 mg/dL rather than < 130 mg/dL for people in the moderately high-risk group. This group includes people with 2 or more cardiovascular risk factors and a 10-20% risk of a cardiovascular event in the next 10 years according to the Framingham Risk Assessment. 

When using medications to lower the cholesterol level in high- and moderately high-risk people, it is now advised that the medications should lower the LDL cholesterol levels by at least 30-40%. 

Therapeutic lifestyle changes are now recommended in ALL people in the high- or moderately high-risk categories, regardless of their LDL cholesterol level.

¹National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), 2001.
²Grundy, Scott, Cleeman, James I., Bairey Merz, C. Noel, et al. Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation 2004; 110: 227-239.