Knowing only your total cholesterol isn’t enough. Unlike total cholesterol, LDL (“bad”) cholesterol can only be checked after a nine-to-12-hour fast. The same blood test should measure your HDL (“good”) cholesterol and your triglycerides. No matter how good the numbers are, you’ll need a new test every five years. Here’s how the NCEP rates the results: LDL (“bad”) Cholesterol (mg/dL) under 100 Optimal 100-129 Near Optimal 130-159 Borderline High 160-189 High 190 or more Very High Total Cholesterol (mg/dL) under 200 Desirable 200-239 Borderline High 240 or more High HDL (“good”) Cholesterol (mg/dL) under 40 Low 60 or more High   If you already have clogged arteries or diabetes, you’re at greater risk for a heart attack. That means you need to get your LDL below 100 (see Step Five). Here’s what your doctor should check for:  Clinical heart disease. Signs of heart disease include having had a previous heart attack, angina pectoris (chest pain when you walk or run), or procedures to prevent a heart attack (like coronary bypass surgery or angioplasty).  Symptomatic carotid artery disease. The “symptoms” are a stroke or a TIA (transient ischemic attack, also called a temporary or mini-stroke) that the doctor can trace to clogged carotid (neck) arteries.  Peripheral arterial disease. If the arteries leading to your legs or feet are clogged, it can cause cramping or fatigue when you’re active. People with this disease have a higher risk of heart attacks and strokes.  Abdominal aortic aneurysm. An aneurysm is a ballooning out of a section of a blood vessel, much like a bulge in an over-inflated inner tube. If the bulge occurs in a section of the aorta (the largest artery in your body) that passes through your abdomen, it’s called an abdominal aortic aneurysm.  Diabetes. People with diabetes are as likely to have a heart attack as people who have already had one. Diabetics also need aggressive treatment because they are more likely to die during or soon after a heart attack than non-diabetics.   The more risk factors you have, the lower your LDL needs to be (see Step Five). Here are the major ones:  Cigarette smoking.  High blood pressure. You have high blood pressure (hypertension) if you have a systolic blood pressure of at least 140 or a diastolic pressure of at least 90 or if you take medicine to lower your blood pressure.  Low HDL (“good”) cholesterol. An HDL under 40 is too low. However, if your HDL is at least 60, it cancels out one of the other risk factors.  A family history of premature heart disease. If your father or brother had heart disease before age 55 or your mother or sister had it before age 65, you have this risk factor.  Age. Men aged 45 or older and women aged 55 or older have this risk factor.     less than 10 percent,   10-20 percent, or   more than 20 percent.   The answer may help you with Step Five.   The higher your risk of heart attack, the lower your LDL needs to be. Use your ten-year risk (from Step Four), your risk factors (from Step Three), and the presence of illness (from Step Two) to see how low your LDL should be. Risk Category   10-Year Risk LDL Goal (mg/dL) heart disease or diabetes OR above 20% less than 100 2+ risk factor AND 20% or less less than 130 0-1 risk factor AND 20% or less less than 160   If your LDL is higher than your LDL goal, give yourself about 12 weeks to lower it with a diet that’s low in saturated fat and cholesterol (see “Doing It With Diet,” p. 8 of the Healthletter), more exercise (roughly 30 minutes a day), and weight loss (if necessary). If your LDL isn’t down to the goal after six weeks, the NCEP recommends adding foods rich in soluble fiber (like oatmeal, beans, peas, and oranges) and cholesterol-lowering margarines like Benecol and Take Control.   If your LDL is still too high after about 12 weeks of diet and exercise, it’s time to consider drugs. For most people, the first choice is a statin drug (like Zocor, Pravachol, or Lipitor). They slash LDL by 18 to 55 percent, trim triglycerides by seven to 30 percent, and bump HDL up by five to 15 percent. They protect against heart attacks and strokes and may lower the risk of diabetes, osteoporosis, and dementia. Although statins carry a risk for liver abnormalities and muscle problems, both side effects are quite rare.     Statins aren’t the best choice for everyone. People with high triglycerides and low HDL may be better off with niacin or fibric acids (Lopid or Lipidil). They’re more likely to have what the NCEP calls “the metabolic syndrome.” Others call it “syndrome X” or insulin resistance (see March 2000, cover story).   If you have any three of these five risk factors, you probably have the metabolic syndrome and have an increased risk of heart disease.   Risk Factor   Abdominal Obesity   Men  more than 40-inch waist*   Women more than 35-inch waist   Triglycerides (mg/dL) 150 or higher   HDL cholesterol (mg/dL)   Men under 40   Women under 50   Blood Pressure (mm Hg) 130 (systolic) or higher or   85 (diastolic) or higher   Fasting Blood Sugar (mg/dL) 110-125   * In some men, a 37- to 39-inch waist can be a risk factor.   If you have the metabolic syndrome, you need to:  Treat the underlying causes (being overweight and inactive):   lose weight (if your waist is too large), and   exercise (even if you don’t shed a pound).  Treat the other risk factors:   lower your blood pressure (with diet or drugs),   talk to your doctor about taking aspirin (to lower the risk of blood clots that could cause heart attacks), and   lower your triglycerides.    Triglycerides (mg/dL) under 150 Normal 150-199 Borderline High 200-499 High 500 or more Very High   If your triglycerides are 150 or higher, you first need to reach your LDL goal (see Step Five), then:   lose excess weight, and   exercise more.   If you reach your LDL goal and your triglycerides are between 200 and 499, you can either:   increase the dose of statin or add another medication to further lower your LDL, or   take niacin or a fibrate drug to lower your VLDL (very-low-density lipoprotein).   If your triglycerides are 500 or higher (no matter what your LDL), you first need to lower them to reduce your risk of pancreatitis (inflammation of the pancreas):   eat a very-low-fat diet (less than 15 percent of calories from fat),   lose excess weight,   exercise more, and   take niacin or a fibrate drug.   Very few people have low HDL and not high triglycerides. If you’re one of them, you first need to reach your LDL goal (see Step Five), then:   exercise more,   lose excess weight   consider taking statins, niacin, or a fibrate drug, depending on your triglycerides and your other risk factors.   1 http://www.nhlbi.nih.gov/guidelines/cholesterol/dskref.htm