Glenn N. Levine, MD, FACC, FAHA

1. Who should be screened for hypercholesterolemia?

    The National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) recommends that all adults age 20 years or older should undergo fasting lipoprotein profile every 5 years. Testing should include total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides.

2. True or false: Coronary atherosclerosis is common in persons in their 20s and 30s.

    True. Autopsy and intravascular ultrasound (IVUS) studies have demonstrated detectable atheromas and/or atherosclerosis in 50% to 69% of asymptomatic young persons.

3. What are the ATP III classifications of LDL cholesterol, total cholesterol, HDL cholesterol, and triglyceride levels based on measured values?

    The values, as denoted in ATP III, are given in Table 41-1. Note that since publication of this classification in 2001, a goal of LDL less than 70 mg/dL has emerged as desirable in some very high-risk populations and thus an LDL of significantly less than 100 mg/dL would now be considered optimal in such patients. To convert the values in the table to mmol/L, divide by 88.6.

4. What are important secondary causes of hypercholesterolemia?

5. What is a lipoprotein?

    A lipoprotein is the particle that transports cholesterol and triglycerides. Lipoproteins are composed of proteins (called apolipoproteins), phospholipids, triglycerides, and cholesterol (Fig. 41-1).

6. What is lipoprotein (a)?

    Lipoprotein (a), often represented as Lp(a), is an LDL-like particle that contains apolipoprotein B (apo B). It has independently been correlated with an increased risk of adverse cardiovascular event in certain patient populations. According to a 2008 consensus report from the American Diabetes Association and American College of Cardiology Foundation, “the clinical utility of routine measurement of Lp(a) is unclear, although more aggressive control of other lipoprotein parameters may be warranted in those with high concentrations of Lp(a).”

7. What is the minimal LDL goal for secondary prevention?

    The minimal LDL goal for secondary prevention in patients with established coronary artery disease (CAD) is an LDL less than 100 mg/dL. This is also now the goal in patients with coronary heart disease risk equivalents (see Question 8). In an update to ATP III, it was emphasized that an LDL less than 100 mg/dL is a minimal goal of therapy. In light of more recent studies (Pravastatin or Atorvastatin Evaluation and Infection Therapy [PROVE-IT], Heart Protection Study [HPS], and Treating to New Targets [TNT]), a goal of LDL less than 70 mg/dL should be considered in patients with coronary heart disease at very high risk. Patients with coronary heart disease classified as very high risk include those with the following:

8. What is a coronary heart disease risk equivalent?

    Patients with established coronary heart disease (those being treated for secondary prevention) have been recommended for the most aggressive treatment for elevated LDL levels. ATP III established coronary heart disease risk equivalents to denote those at high risk for cardiovascular disease and events, who would warrant equivalently aggressive lipid therapy as provided to those with established CAD. ATP III recommends that patients with these risk equivalents should have LDL levels lowered to below 100 mg/dL at a minimum. These coronary heart disease risk equivalents include the following: