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Secondary Prevention of Cardio-Vascular Disease

Non-HDL cholesterol

The United States of America's ATP III guidelines recognise the role in atherogenesis of particles other than LDL. These guidelines do not, however, recommend abandoning the measurement of total cholesterol, LDL cholesterol and HDL cholesterol in favour of measurement of apo-B/Apo-A1 ratios. These guidelines instead recommend setting a secondary goal for treatment for "non-HDL cholesterol" level.

Risk Category LDL Goal (mmol/l) Non-HDL Goal (mmol/l)
CHD and CHD Equivalent <2.5

(updated mid-2004- now includes option to lower LDL further for secondary prevention)		 <3.3
2 or more risk factors and ten year CHD risk less than 20 percent <3.3 or 4.1

for risk greater than or less than 10 percent respectively

(updated mid-2004- includes option of treating moderate risk patients with statin if LDL cholesterol is between 2.5 and 3.3 mmol/l)		 <4.1 or 4.9

dependent on level of risk
0-1 risk factor <4.1 <4.9

If triglyeride levels are above about 6 mmol/l then the first goal is to lower this to reduce risk of pancreatitis. Statins, amongst other drugs, lower triglyeride levels.

If triglyceride levels are less than 6 mmol/l, then the primary goal is to attain the LDL target. Once this has been achieved, if the triglyeride levels are above 2.3 mmol/l then one should try to attain the non-HDL cholesterol target. Non-HDL cholesterol is calculated by substracting HDL cholesterol levels from total cholsterol levels obtained when fasting. By this means, we might end up treating patients with raised apo-B levels more intensively without actually measuring apo-B levels!

It will be noted that the focus is largely on lowering LDL cholesterol and non-HDL cholesterol levels, not on raising HDL cholesterol levels.

Trying to raise HDL cholesterol with nicotinic acid is recommended if there is no elevation of triglycerides, otherwise it is recommended that one tries to attain the non-HDL cholesterol target.

If one wishes to instead measure and lower apo-B levels then, in the highest risk groups, a level less than 0.9/l (possibly less than 0.8g/l) is an alternative secondary target after attaining the LDL cholesterol target.

It should also be noted that the target for all of the highest-risk patients, in the United States of America, continues to be set lower and lower- an update to the NCEP's ATP III guidelines indicate that lowering LDL cholesterol under 1.8 mmol/l is an option of the highest risk patients in light of recent trial results, however, results of further trials are awaited before this target is set as the new goal.

Apart from providing an option for lowering the LDL cholesterol target further for secondary prevention, the updated USA guidelines also provide for an option for primary prevention for treatment with a statin even if LDL cholesterol levels are less than 3.3 mmol/l, if the patient is at "moderately increased risk".

Hitesh Patel, Cardiologist
28th March, 2005

Reference:
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). Final Report.
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