Lower Cholesterol By:
Determining LDL Goals




You Need Lower Cholesterol? Where Do You Start?


Lower cholesterol can mean more than one thing.

  • We can try to influence total cholesterol.
  • We might try to raise HDL cholesterol.
  • We could try to reduce LDL oxidation.
  • We could focus on the reduction of LDL levels.

Actually all of these approaches are beneficial to optimal heart health. And most cholesterol management therapy is designed to influence more than one of these.

But the main focus is usually to lower cholesterol risk by reducing LDL cholesterol because of its strong influence on coronary heart disease.
I wish I could take credit for this idea. But I can’t. The third Adult Treatment Panel (ATP III) supports this approach to cholesterol management.

ATP III is the result of the National Cholesterol Education Program’s (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.

As mentioned in the section on Risk Assessment, ATP III recommends lowering LDL cholesterol levels as the primary target for preventing and treating coronary heart disease (CHD) and related heart events. In other words, if a patient is at high risk for CHD because of multiple risk factors the primary focus for treatment is to reduce LDL cholesterol.

ATP III recognizes a number of risk factors for coronary heart disease. Among them are…

  • Cigarette smoking
  • High blood pressure (at least 140/90 mmHg or taking an antihypertensive medication)
  • Low HDL cholesterol (less than 40 mg/dL)
  • Age (men: at least 45 yrs.; women: at least 55 yrs.)
  • Family history of early CHD Development
  • Diabetes

There are, of course, several other risk factors. The above is just a sampling. But depending on the number of CHD risk factors you have you will be classified into one of…





Three Risk Categories of Cholesterol Management

As science would have it each of us must be placed in a risk category. Below is a brief description of each category. You can actually see a bit more detail on these categories in the section on LDL Lowering Therapy in Three Risk Categories.

The Highest Risk Category

The category for highest risk consists of patients who have documented coronary heart disease or CHD equivalents. Even if a person does not have CHD he may have other risk factors that place him at equal risk for a major heart event within the next ten years. These 'other risk factors' are what we mean by CHD risk equivalents.

The risk for this group is greater than 20%. In other words there is at least a 21% chance that a person in this risk group will develop CHD or experience a recurring CHD related event within the next 10 years.

The CHD risk equivalents recognized by ATP III are:

  • Other forms of atherosclerosis (clogging of the arteries) including carotid artery disease, abdominal aortic aneurism or peripheral artery disease.
  • Diabetes
  • A combination of other risk factors that elevate one to a risk factor of greater than 20%.

Persons in this highest risk category have the lowest goal for LDL cholesterol. It makes sense that the patients with the highest risk should receive the most intensive LDL lowering efforts. For such patients it is urged that LDL cholesterol levels do not exceed 100 mg/dL.

The Second Highest Risk Category

The second risk category consists of folks with at least two risk factors that combined elevate the risk up to 20% chance for CHD. Risk is estimated from the Framingham Risk Scores which, of course, resulted from the Framingham Heart Study.

The Framingham risk questionnaire identifies the existence of multiple risk factors (2+) as listed above and scores a patient accordingly. For patients that fall into this category there is a 10-20% risk for CHD development within the next ten years.

It is recommended that people in this category get their LDL cholesterol below 130 mg/dL.

The Category of Lowest Risk

The third risk category consists of people who have no more than one risk factor from the list above as scored by the Framingham risk scores. Most people in this category have less than a 10% chance for CHD or related heart event within the next decade. The LDL cholesterol goal for this group is not nearly as aggressive.

It is recommended that people in this group lower cholesterol (LDL) below 160 mg/dL.
Here is a bit of a side note. The LDL goals are set for treatment purposes. It implies that it is much more critical for someone in the highest risk category to get their LDL cholesterol down. Why?

Every evaluation is made against the backdrop of 10-year risk. LDL levels influence a person’s likelihood for experiencing a CHD related heart event in the next ten years.

Does that mean that if you are in the lowest risk category you should be content with LDL cholesterol barely under 160 mg/dL? I don’t think so. Estimating ten year risk is not about optimal heart health. It is about treatment efforts to avoid heart disease. There is a difference.


To Lower Cholesterol or Not - Estimating 10 Year Risk

To determine what type of therapy to lower cholesterol – if any – a person is to receive his or her CHD risk must first be ascertained. The risk, of course, is determined based on the likelihood of experiencing a CHD related event in the next ten years.

The Highest Risk Category

As mentioned earlier...

The highest category of risk consists of persons with manifested coronary heart disease or some other form of atherosclerosis.
This category of patients is fairly easy to determine. Their risk for a recurring CHD related event within the next 10 years is greater than 20%. Therefore they would receive the most stringent cholesterol management measures. It is absolutely imperative that they get their LDL down to no more than 100 mg/dL.


Heart Health Note:

Atherosclerosis (clogged arteries) is a great heart health hazard. It is the foundational process for the development of coronary heart disease.

Research has shown that Omega-3 rich foods help prevent atherosclerosis.


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Learn more about Omega-3 and Heart Disease.



The Medium Risk Category

But for other folks risk assessment is a little more involved. The first step is to count the total number of risk factors from the list above. For those patients with at least two risk factors risk assessment is carried out using Framingham scoring. This involves several steps of filling in blanks or checking categories including...

  • Age
  • Cholesterol levels
  • Smoking habits
  • Blood pressure
Each step produces a score. The scores are tallied up at the end giving a total score. The higher the score the higher the risk. This in turn justifies the most aggressive LDL goals and treatments.

The Lowest Risk Category

For patients with no more than one risk factor Framingham scoring usually is not necessary. The exception might be for such people with very high LDL levels. In such cases a patient’s doctor may recommend pursuing LDL lowering drug therapy to reduce long-term risk for developing CHD.





Additional Risk Factors

Framingham scoring depends on a distinct list of risk factors. But there are other risk factors that come into play when calculating risk.

These factors are recognized to increase the risk for coronary heart disease. In other words, a patient may experience other factors that contribute to the development of CHD. However having one or more of these factors does not alter the patient’s goal for LDL cholesterol levels.

The first classification of these additional risk factors is life-habit risk factors. They are so named because they are influenced by our lifestyle choices. These factors include…

  • Obesity
  • Lack of exercise
  • Diets that promote the development of atherosclerosis
The other classification in this grouping is emerging risk factors. These include the following:

Lipoprotein(a) or Lp(a) is similar to LDL in its composition and has been associated with the development of atherosclerosis and is therefore marked as a significant risk factor. It further has been associated with cardiovascular mortality in patients with type-2 diabetes.

Prothrombotic factors are agents that promote the development of a thrombus (an aggregation of blood factors causing vascular obstructions. They are very similar to a clot).

Proinflammatory factors are agents that cause inflammation.

Subclinical atherosclerotic disease involves the formation of clots in the walls of the arteries. Subclinical refers to the fact that the disease may be in its early stages and has not yet been manifested.

Impaired fasting glucose is a prediabetic stage where the patient’s blood sugar is unusually high but not high enough to classify them as diabetic. Many people who develop type-2 diabetes go through this stage. People in this category tend to be more likely to suffer from a heart attack.

Metabolic Syndrome is not a single risk factor like the others. It is a condition where the patient has a variety of risk factors from both of the above mentioned categories, (i.e. life-habit risk factors and emerging risk factors).

Such patients often suffer from…

  • Abdominal obesity
  • Low HDL cholesterol
  • Small LDL particles
  • High triglycerides
  • Hypertension
  • Insulin resistance

For people with metabolic syndrome the primary goal for treatment is still to lower cholesterol (LDL). The treatment of metabolic syndrome itself becomes the secondary goal.

For more information on Metabolic Syndrome please click here.

Heart Health Note:

Triglycerides have become very important to heart health. Keeping Triglycerides down is essential.

The American Heart Association recommends 2 to 4 grams of Omega-3 for anyone with high triglycerides.


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Read more about Omega-3 and Triglycerides.



Lower Cholesterol Goals Summary

Ideally, of course, everyone should have their LDL cholesterol levels under 100 mg/dL. In fact recent research suggests that LDL goals should be even lower. However the patients in lower risk groups have less aggressive LDL goals partly because of the high cost of drug treatment.

All of us with elevated LDL cholesterol should alter our lifestyles in an attempt to lower LDL and therefore our risk as well. But for people in high risk categories it is much more imperative. Also the benefit received from drug therapy is often greater for patients in the higher risk categories.

As the cost of drug therapy comes down the decision to use drugs to treat patients in lower risk categories will likely shift. However, lower drug costs will not lessen the side-effects that can accompany many drugs.

Only our doctors can sort through all of these variables to determine the best treatment. Perhaps, though, this information gives us a better idea concerning the complexity of a doctor’s job in diagnosing and treating coronary heart disease and other related heart conditions.

That being said it is important to note that all of us can do some things to reduce our high cholesterol risk. Much of the focus of CHD prediction and treatment is outside of the realm of drug therapy. In many cases lifestyle changes are the best means to lower cholesterol. After all, for many of us, lifestyle choices are what placed us in a high risk category in the first place.

The particulars of lifestyle changes in an attempt to lower cholesterol are discussed elsewhere in the cholesterol section of this website. You can read the cholesterol main page and follow the links to the sections that interest you.

Or if you are in a hurry, as I usually am, you can go straight to the section on lifestyle changes we can make to affect our cholesterol.

Whatever you do, don’t be uninformed. Optimal heart health goes beyond us. It reaches those who love us. For their sakes, as well as your own, do everything you can to have a healthy heart.

Click here for an all natural cholesterol care supplement.

Therapeutic Lifestyle Changes for Cholesterol Management


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