Disclaimer – always consult with your personal MD to discuss a personalized treatment plan
“These cholesterol goal guidelines are for curious patients interested in knowing how we, your doctors, choose your treatment plan.”
They will to point you in the right direction and help you calculate your cholesterol goals.
“You could have a high TC and not be at risk; The opposite is also possible. A normal TC doesn’t mean you are not at risk.”
‘High cholesterol’ does not necessarily refer to your Total Cholesterol (TC).
Most people are unaware of this.
Let’s review three examples of TC values
I will illustrate my point using three patient lipogram examples:
- My partner J,
- our friend Mr. A,
- and myself.
It looks worse for me when comparing our S-cholesterol (TC) counts, don’t you think?
However, this is not the case.
- I am low-risk,
- J is at high-risk, and
- Mr. A, with a normal TC, has the highest risk of all.
Now that I’ve got your attention let’s find out why.
“First, I will explain the process and calculations. Then, I will use our three examples as case studies to prove my point!”
Units of measurement
In South Africa, the unit of cholesterol we work with is mmol/L; some countries use mg/dL. Use this cholesterol units converter if mmol/L is unfamiliar to you.
Let’s quickly recap a few basics from my article ‘How to calculate total cholesterol and is it important?’
What is a lipogram?
Then, we will move on to calculating risks and LDL goals.
What is a lipogram?
Also known as a lipid (fat) profile. A lipogram is a blood test that lists different fat types and their calculated ratios. These ratios help with vascular risk prediction.
Your full lipogram lists:
- Total Cholesterol,
- LDL,
- HDL,
- and triglyceride levels.
Total cholesterol = LDL + HDL + 20% triglycerides.
If you’d like a recap on these fat types, read ‘What are the forms or types of cholesterol?’
How can the lipogram tell me about risk?
The Chol:HDL ratio
The Chol:HDL ratio is the most important calculation from the lipogram because:
- It is the first risk indicator, and
- helps to decide on a treatment plan.
“If this ratio is very high, doctors might feel nervous about only implementing lifestyle changes and decide to add medication, a statin, immediately.
We also consider how far off-goal the patient is.”
What other tests do I need to calculate my risk?
The reason that you are checking cholesterol is to evaluate your risk of heart attacks and stroke.
Therefore, other risk factors should be checked at the same appointment.
- Fasting blood sugar (glucose),
- weight and height,
- smoking status and
- blood pressure.
Screen for other conditions that push up cholesterol.
- Excess alcohol intake with a GGT blood test.
- Underactive thyroid with a TSH blood test.
What about the cholesterol goal guidelines?
Again, I will stress that we are not referring to your total cholesterol (TC) when it comes to the treatment goal.
The bad cholesterol in LDL is what needs to come down.
“We calculate your LDL goal.”
To calculate your LDL goal, we need your:
- lipogram,
- blood pressure reading and
- smoking status.
How do we work out how low the LDL-C needs to be?
“Higher risk = lower goal”
Patients with existing organ disease are automatically ultra-high risk.
A history of stroke, a heart attack, or severe kidney disease are examples.
The LDL goal for these patients is < 1.4.
If you are not in this ultra-high-risk category, your doctor will guide you by considering:
- your history and
- using tools, e.g., the Framingham chart.
Also read: How low is low enough? If you have normal cholesterol, is it low enough?
Next, let’s look at the tools.
The Framingham 10-year Risk Assessment Chart
In South Africa, we most often use the Framingham chart.
The Framingham 10-year Risk Assessment Chart is one tool that guides us on LDL goals. It estimates your chance of heart attack in the next ten years.
To calculate risk, it uses your:
- lipogram,
- sex,
- age,
- blood pressure reading and treatment status, and
- smoking history.
Another is the SCORE Chart, which uses manual charts or online calculations.
Warning: An online Framingham 2008 calculator is outdated and underestimates risk. Use the updated chart below for accurate results.
What if I only have an LDL to work with?
What about cash-strapped patients who only have an LDL to work with?
“These are my goal recommendations, considering the below risk factors.”
- Male >50 years old
- Female >55 years old
- On high blood pressure medication
- Smoking – any number of cigarettes in the past 5 years. A study by H. Mannan “observed that any major reduction in the risk of CVD incidence did not occur until after five years since quitting.” 1
One risk factor – LDL goal < 3
Two risk factors – LDL goal < 2.5
Three risk factors – LDL goal < 1.8
Disclaimer: This is based on my experience in practice and is only a guideline. Always consult your doctor, as you might have additional conditions to consider.
Also read: How to lower my cholesterol – 7 simple steps
Summary of cholesterol risk and goal
- Total cholesterol is useless on its own.
- Ideally, a lipogram is necessary to assess risk and goals accurately.
- Chol:HDL ratio calculates immediate risk and helps your doctor triage lifestyle change vs statin therapy.
- The Framingham 10-year Risk Assessment Chart is one tool used to calculate the LDL goal.
- Ensure you use an up-to-date tool to calculate LDL goals; they have dropped lower with every guideline review.
Also read: How to lower my cholesterol – 7 simple steps
Case studies
Step 1 – Let’s look at our three full lipograms
Step 2 – Chol:HDL Ratio (Dorianne vs J vs A)
This table shows the hidden risk of a low HDL.You can have a normal TC, but still be at high cardiovascular risk.
| Dorianne | J | A | |
|---|---|---|---|
| Chol:HDL Ratio | 2.5 | 5.8 | 6 |
| Chol:HDL Risk | Low | High | High |
| Total Cholesterol | 6 | 5.8 | 4.3 |
| HDL | 2.4 | 1 | 0.8 |
| Sex | Female | Male | Male |
| Age | 47 | 55 | 42 |
In South Africa, the unit of cholesterol we work with is mmol/L; some countries use mg/dL. Use this cholesterol units converter if mmol/L is unfamiliar to you.
Step 3 – Ours 3 patients and the Framingham 10-year Risk Assessment Chart ∣ LDL goal calculation
Let’s look at our three examples.
| Dorianne | J | A | |
|---|---|---|---|
| Sex | Female | Male | Male |
| Age | 47 | 55 | 42 |
| Total Cholesterol | 6 | 5.8 | 4.3 |
| HDL | 2.4 | 1 | 0.8 |
| Chol:HDL Ratio | 2.5 | 5.8 | 6 |
| Chol:HDL Risk | Low | High | High |
| Blood Pressure | 110 | 124 | 132 |
| On BP medication | No | No | Yes |
| Smoking in the past 5 years | No | No | Yes |
| Framingham risk | Low | High | High |
| Framingham 10-year risk of an event | 2.1% | 15.6% | 25.3% |
| LDL goal | 3 | 1.8 | 1.8 |
In South Africa, the unit of cholesterol we work with is mmol/L; some countries use mg/dL. Use this cholesterol units converter if mmol/L is unfamiliar to you.
“Point proved.
Our friend Mr. A, with the normal cholesterol is at the highest CV risk.
I have the highest TC, but the lowest risk.”
In 2020, the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) reviewed LDL goals and lowered them further. 2 In 2019, J and Mr. A would have aimed for an LDL < 2.5
How low should you go?
“In theory, I am low risk, and my LDL cholesterol of 2.9 is at goal.”
Is this really low enough?
Maybe not!
In the USA, the cholesterol unit is mg/dL; some countries use mmol/L. Use this cholesterol units converter if mg/dL is unfamiliar to you.
References
- Mannan, H., Stevenson, C., Peeters, A., Walls, H., & McNeil, J. (2010). Framingham risk prediction equations for incidence of cardiovascular disease using detailed measures for smoking. Heart International, 5(2). https://doi.org/10.4081/hi.2010.e11
- Mach, F., Baigent, C., Catapano, A. L., Koskinas, K. C., Casula, M., Badimon, L., Chapman, M. J., De Backer, G. G., Delgado, V., Ference, B. A., Graham, I. M., Halliday, A., Landmesser, U., Mihaylova, B., Pedersen, T. R., Riccardi, G., Richter, D. J., Sabatine, M. S., Taskinen, M., . . . Patel, R. S. (2020). 2019 ESC/EAS Guidelines for the management of dyslipidaemias: Lipid modification to reduce cardiovascular riskThe Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS). European Heart Journal, 41(1), 111-188. https://doi.org/10.1093/eurheartj/ehz455
