At what levels of total low- or high-density lipoprotein cholesterol should diet/drug therapy be initiated? European guidelines.

The control of coronary artery disease depends primarily on its prevention at an early stage. Researchers generally agree that early prevention depends on the elimination or treatment of known risk factors, among which hyperlipidemia occupies a central position. Two European Consensus Conferences have concluded that therapy of hyperlipidemia should always start with dietary counseling. First, subjects with body mass indexes (weight/height) greater than 27 should lose weight. Second, the lipid-lowering diet should provide 55% of calories from carbohydrates; 10 to 15% from protein; and up to 30% from fat comprising 10% each of saturated, monounsaturated and polyunsaturated fatty acids; less than 300 mg/day cholesterol; 35 g/day of fiber derived largely from legumes and other vegetables; and fruit. Further reduction of fat consumption (to 20 to 25% of total energy) and of cholesterol (to less than 150 mg/day) may be attempted when patients respond inadequately to the standard diet. The goal of treatment is to minimize the risk of coronary artery disease and of pancreatitis. Where possible, a low-density lipoprotein cholesterol level of 135 mg/dl (3.5 mmol/liter) should be the goal in hypercholesterolemic patients with multiple or severe risk factors and a level of 155 mg/dl (4 mmol/liter) in the absence of other risk factors. Also, high-density lipoprotein cholesterol greater than 35 mg/dl and triglycerides less than 200 mg/dl are considered important goals of treatment. Some patients with hyperlipidemia do not respond adequately to diet and correction of underlying causes; drug treatment should then be instituted, but careful attention to diet should be continued.