DƯỢC LÍ Goodman & Gilman's The Pharmacological Basis of Therapeutics 12th, 2010

Table 31–3
Treatment Based on LDL-C Levels (2004 Revision of NCEP Adult Treatment Panel III Guidelines)
LDL-C GOAL NON-HDL-C THERAPEUTIC THRESHOLD FOR
RISK CATEGORY (mg/dL) GOAL (mg/dL) LIFESTYLE CHANGE DRUG THERAPY (mg/dL)
Very high risk <70 a <100 No threshold No threshold
Atherosclerosis- (initiate change) (initiate therapy)
induced CHD plus one of:
• multiple risk factors
• diabetes mellitus
• a poorly controlled
single factor
• acute coronary syndrome
• metabolic syndrome
High risk <100 a <130 No threshold No threshold
CHD or CHD
equivalent
Moderately high risk <130 <160 No threshold ≥130
2+ risk factors (optional <100) (100-129) b
10-year risk: <10–20%
Moderate risk <130 <160 No threshold >160
2+ risk factors
10-year risk <10%
0–1 risk factor <160 <160 No threshold ≥190
(optional: 160–189) c
a
If pretreatment LDL-C is near or below LDL-C goal value, then a statin dose sufficient to lower LDL-C by 30-40% should be prescribed.
b
Patients in this category include those with a 10-year risk of 10-20% and one of the following: age >60 years, three or more risk factors,
a severe risk factor, triglycerides >200 mg/dL and HDL-C <40 mg/dL, metabolic syndrome, highly sensitive C-reactive protein (CRP) >3 mg/L, and
coronary calcium score (age/gender adjusted) >75th percentile.
c
Patients include those with any severe single risk factor, multiple major risk factors, 10-year risk >8%.
After attaining the LDL-C goal, additional therapy may be necessary to reach the non-HDL-C goal. CHD, coronary heart disease; CHD equivalent,
peripheral vascular disease, abdominal aortic aneurysm, symptomatic carotid artery disease, >20% 10-year CHD risk, or diabetes mellitus; HDL-C,
high-density-lipoprotein cholesterol; LDL-C, low-density-lipoprotein cholesterol; NCEP, National Cholesterol Education Program.
based on measurements of levels of cholesterol or apoA-I and apoB
(Mora, 2009).
In addition to plasma lipid levels and a fasting glucose level,
each subject requires an evaluation to assess the presence or absence
of the other major CVD risk factors: age, a family history of premature
CVD event, smoking, hypertension, type 2 diabetes mellitus,
and obesity (Table 31–5). There are a host of additional novel risk
factors that are being evaluated to determine if they will improve
current risk prediction assessment schemes based on lipid levels and
the established major CVD risk factors (Table 31–5). Thus far, routine
use of any of these novel risk factors has not been shown to
improve risk prediction (Folsom et al., 2006; Lloyd-Jones and Tian,
2006). However, in certain primary prevention patients, two of the
recently described risk factors, C-reactive protein (CRP) and assessment
of the extent of coronary calcification, may improve risk
assessment beyond that based on the traditional major risk factors
(Tables 31–3 and 31–5).
Using the values for levels of total cholesterol and HDL-C
and the results of the assessment for the other major CHD risk factors,
the next step is to calculate a person’s risk of having a CHD event
over the next 10 years. Risk prediction tables based on observational
studies conducted by the Framingham Heart Study are used to calculate
this 10-year risk. This approach to risk assessment was
adopted by the NCEP, but in the 2001 ATP III guidelines, the risk
prediction model predicted only the 10-year risk of having a fatal or
nonfatal myocardial infarction. However, the same risk factors that
are associated with development of myocardial infarction also promote
other CVD events, including stroke, transient ischemic attack,
peripheral vascular disease, and heart failure. Furthermore, many
patients who develop acute coronary syndrome do not sustain a
myocardial infarction because of thrombolytic therapy and revascularization
procedures (angioplasty and bypass graft surgery).
Because cholesterol-lowering therapy is beneficial to prevent CVD
events in patients with any of these manifestations of CVD, it
became apparent that it would be useful for primary care physicians
to be able to predict a patient’s risk of developing any one of these
manifestations of CVD, not just CHD. New general CVD 10-year
risk prediction tables are now available from the Framingham
Heart Study (D’Agostino et al., 2008; Wickramasinghe et al., 2009)
(Table 31–6). Ten-year risk calculated with the general CVD tables
will exceed 10-year risk calculated using the CHD tables from the
ATP III guidelines.