Image for cholesterol article The National Cholesterol Education Program (NCEP) offers cholesterol guidelines for men and women.

In 2004, NCEP updated its guidelines, particularly for high risk people. “Very high risk” refers to people who have had a recent heart attack or who have known vascular disease plus other serious risk factors (eg, diabetes, smoking, metabolic syndrome). The update:

  • Lowers the limit at which low-density lipoprotein (LDL or "bad") cholesterol levels are considered “too high” and potentially in need of drug treatment
    • Goal for people at high risk for a heart attack: 100 milligrams per deciliter (mg/dL) (2.6 millimole per liter [mmol/L])
    • Some very high risk people with LDL less than 100 mg/dL (2.6 mmol/L) could be treated with drugs
  • Offers, as an option, lowering the ideal goal of LDL treatment to 70 mg/dL (1.8 mmol/L) in very high risk people

Cholesterol and Heart Disease

High levels of LDL cholesterol and/or low levels of high-density lipoprotein (HDL, or “good”) cholesterol, are major risk factors for heart attack and stroke, two of the most common causes of death in the US.

The good news is that most people can control major heart disease risk factors, including cholesterol levels, smoking, excessive weight, lack of exercise, high blood pressure, and type 2 diabetes.

Screening for lipid disorders like high cholesterol depends on your age and whether you have any risk factors for heart disease. In general, if you are a healthy adult aged 20 or older, your doctor may recommend that you have a screening test every five years. The test results for total cholesterol are:

  • Less than 200 mg/dL (5.2 mmol/L)—desirable
  • 200-239 mg/dL (5.2-6.1 mmol/L)—borderline high
  • Over 239 mg/dL (6.1 mmol/L)—high

If your total cholesterol level is over 240 mg/dL (6.2 mmol/L), you have a higher risk of heart disease compared to someone whose cholesterol is below 200 mg/dL (5.2 mmol/L).

A Run-Down of the Guidelines

The guidelines propose different recommendations depending on a person’s degree of risk of heart attack within the next ten years. This risk is determined by the presence of several risk factors, including history of heart attack or stroke, unstable or stable angina (chest pain), history of coronary artery procedures, evidence of clogged arteries (myocardial ischemia), diabetes, metabolic syndrome, high LDL cholesterol, low HDL cholesterol, high blood pressure, smoking, family history of heart disease, and age.

There are three major risk levels:

  • High risk (over 20% chance of heart attack within ten years)
  • Moderately high risk (10% to 20% chance)
  • Lower risk (under 10% chance)

The guidelines do not change cholesterol management recommendations for those at lower risk of heart attack, only for those at moderately high and high risk. NCEP's updates include:

Risk CategoryDrug Therapy Based on LDL levels
High risk and very high risk
  • If above 130 mg/dL (3.4 mmol/L)
Moderately high risk
  • Consider if above 130 mg/dL (3.4 mmol/L)
Lower risk
  • Consider if above 160 mg/dL (4.1 mmol/L)

The guidelines also now state that drug treatment for high-risk patients must be aggressive enough to achieve at least a 30% to 40% reduction in LDL levels. In addition to drug therapy, NCEP also stresses the importance of initiating therapeutic lifestyle changes in high-risk persons—regardless of cholesterol level—since lifestyle changes can reduce cardiovascular risk in several ways besides lowering cholesterol.

Recommended Treatment

Lifestyle Therapy

NCEP recommends the following lifestyle changes:

  • Eating a diet low in saturated fat and cholesterol
  • Maintaining a healthy weight
  • Getting regular physical activity

Diet and exercise remain the first-line treatment option for high cholesterol in those at low to moderate risk for heart disease. And, most certainly, they are measures of prevention that everyone should heed. NCEP's guidelines recommend aggressive drug treatment only for those at high risk for an adverse coronary event.

If you are concerned about your cholesterol levels and your risk for heart disease, talk to your doctor. There are steps that you can take to reduce the risk.

Drug Therapy

Statins are often prescribed for high cholesterol. They are designed to be used in combination with lifestyle therapy. Statins works by blocking an enzyme (HMG-CoA reductase) that helps the body make cholesterol. The benefit from these medicines may also come from their anti-inflammation properties. Common examples of statins include:

Statin drugs have proven to be effective in reducing cholesterol levels. These medicines may also reduce the incidence of heart attack, stroke, and death.