Every 30-mg/dL increase in low-density lipoprotein cholesterol (LDL) raises the relative risk for CAD by 30%.7 ATP III classifies LDL as the “primary target of cholesterol-lowering therapy.”8Table 4 lists LDL target levels based on other CAD risk factors.
Check fasting lipid profile or serum cholesterol, LDL, HDL, and triglycerides beginning at age 20 and about every 5 years thereafter.8 Total cholesterol
Table 3
JNC 7: What blood pressure readings mean
| Category | Systolic BP (mm Hg) | Diastolic BP (mm Hg) |
|---|---|---|
| Normal | and | |
| Prehypertension | 120-139 | or 80-89 |
| Stage 1 hypertension* | 140-159 | or 90-99 |
| Stage 2 hypertension | 160 | or ≥100 |
| JNC 7: Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure | ||
| *Patients with diabetes mellitus or chronic kidney disease have stage 1 hypertension at >130/80 mm Hg. | ||
| Source: Reference 10 | ||
Acceptable LDL cholesterol levels for adults based on CAD risk
| Risk category | Existing CAD risk factors | LDL goal |
|---|---|---|
| High risk (10-year risk > 20%) | History of diabetes, CAD, symptomatic carotid artery disease, peripheral vascular disease, or abdominal aortic aneurysm | |
| Moderate high risk* (10-year risk 10 to 20%) | >2 risk factors | |
| Moderate risk* (10-year risk | >2 risk factors | |
| Low risk | 0 to 1 risk factor | ≤160 mg/dL |
| CAD: Coronary artery disease | ||
| *Same goals apply to managing moderate high and moderate risk. Find 10-year risk calculations at nhlbi.nih.gov/guidelines/cholesterol. | ||
| Source: Reference 7 | ||
Addressing smoking, obesity
Smoking. Before trying nicotine patches or bupropion, Mr. H should realistically contemplate his risks with continued smoking; if he doesn’t want to stop, periodically encourage him to reconsider.10 Most people know the dangers of smoking but few understand that complete cessation for 1 to 2 years often nearly reverses cardiovascular disease.21
Obesity and lack of exercise go hand in hand. Reducing Mr. H’s waist size to 2 is a reasonable short-term goal. To that end, encourage him to:
- decrease his number of weekly fast-food meals from five to three, with an eventual goal of one per week. As an alternative, microwaveable, low-calorie meals—each with at least two servings of fruits or vegetables—can be prepared at home or work.
- walk 30 minutes three times weekly and progress to 1 hour five times weekly over 6 months. As with any exercise program, remind Mr. H to “start low and go slow.”
The patient’s role in treatment. Patients often feel overwhelmed after getting large amounts of information on CAD risk and may feel hopeless and unenthusiastic about improving their physical health. Work with the primary care doctor to emphasize a patient care plan that clearly defines easily attainable, step-by-step goals. Make sure the patient agrees to these goals.
Case continued: no more supersizing
Mr. H now understands the importance of minimizing his CAD risk and realizes that CAD and many associated risk factors are asymptomatic in the early stages of development.
With help from his doctors, Mr. H quit smoking. He also became more mindful of his caloric intake and the types of foods he was eating. He advanced from briskly walking 30 minutes three times per week to slow jogging 40 minutes five times weekly. He still eats at fast-food restaurants but usually orders broiled chicken, salads, or the occasional burger.
- National Cholesterol Education Program. CAD risk assessment tool and ATP III guidelines. www.nhlbi.nih.gov/guidelines/cholesterol/.
- U.S. Preventive Services Task Force preventive guidelines. www.ahrq.gov/clinic/uspstfix.htm.
- National Heart, Lung, and Blood Institute. Calculate your body mass index. http://nhlbisupport.com/bmi/.
- American Heart Association. www.americanheart.org.