NCEP and American Heart Association medication guidelines for high cholesterol

The U.S. National Cholesterol Education Program's (NCEP's) recommendations for treatment with medicine are based on cholesterol levels and the number of risk factors you have for heart attack.^{1, 2} The guidelines provide a good starting point for treatment. Individual risk assessment is important to determine whether starting medicine to lower your cholesterol is appropriate for you.

If you have any risk for heart disease, therapeutic lifestyle changes (losing weight, exercising, and eating a diet that is low in saturated fat) are recommended, whether or not you are taking medicine.

Risk factors for heart disease include:

• Smoking cigarettes.
• Having high blood pressure or taking blood pressure medicine.
• Diabetes.
• Low HDL cholesterol (below 40 mg/dL).
• Having a first-degree male relative, such as a father or brother, who had heart disease before he was 55 years old; or having a first-degree female relative, such as a mother or sister, who had heart disease before she was 65 years old.
• Age. People over 65 are more likely to have coronary artery disease (CAD).

Use this Interactive Tool: Are You at Risk for a Heart Attack?

Lower risk

People who are at low risk do not have coronary artery disease (CAD) and have one or no risk factors for heart disease. Consider starting medicine when:

• LDL is 190 mg/dL or higher. The goal of medication is to lower LDL below 160 mg/dL.

When LDL cholesterol is between 160 mg/dL and 189 mg/dL, beginning medicine is optional. The goal is still to lower LDL cholesterol to below 160 mg/dL.

Moderate risk

People who are at moderate risk for CAD have 2 or more risk factors and have less than a 10% risk of having a heart attack in 10 years.

Consider starting medicine when:

• LDL is 160 mg/dL or higher. The goal of treatment with medicine is to lower LDL below 130 mg/dL.

Moderately high risk

People who are at moderately high risk for CAD have 2 or more risk factors and a 10% to 20% risk of having a heart attack in 10 years.

Consider starting medicine when:

• LDL is 130 mg/dL or higher. The goal of treatment with medicine is less than 130 mg/dL.
• LDL is 100 to 129 mg/dL. If your goal is less than 100 mg/dL, then medicine is an option.

High risk

People who are at high risk for CAD have more than a 20% chance of having a heart attack in 10 years and have CAD, have had a heart attack, have stable or unstable angina, or have had angioplasty or bypass surgery. This category also includes people who have diseases or conditions that are considered equally as serious as CAD, such as peripheral arterial disease, abdominal aortic aneurysm, transient ischemic stroke or ischemic stroke, and diabetes.

Consider starting medicine when:

• LDL is 100 mg/dL or more. Treatment goal is less than 100 mg/dL, with an option to use medicines to lower LDL to 70 mg/dL, especially for people who are at very high risk (who have CAD and diabetes, acute coronary syndrome, or metabolic syndrome or who smoke cigarettes).
• LDL is less than 100 mg/dL but HDL is below 40 mg/dL or triglycerides are high. Your doctor may consider adding additional medicines (fibrate or nicotinic acid) to a statin.

Additional recommendations

If you have a moderately high or high risk of heart attack and you are obese or physically inactive, or you have high triglycerides, low HDL, or metabolic syndrome, you should begin therapeutic lifestyle changes even if your LDL is below 100 mg/dL.

If you have a moderately high or high risk of heart attack, and your doctor has advised you to take medicines, the guidelines recommend that the treatment be intense enough to lower your LDL 30% to 40%.

Citations

1. Grundy SM, et al. (2001). Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA, 285(19): 2486–2497.

2. Grundy SM, et al. (2004). Implications of recent clinical trials of the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation, 110(2): 227–239. [Erratum in Circulation, 110(6): 763.]