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The Expert Panel of the National Cholesterol Education Program has identified 10 risk factors for the occurrence of an atherosclerotic event. Each of these factors does not represent an independent risk. Male sex, family history of premature coronary events, cigarette smoking (> 10/day), systemic hypertension, diabetes mellitus and severe obesity (>30% overweight) should be viewed as cholesterol-dependent atherosclerotic risk factors and not in themselves as atherogenic. There is no doubt that atherosclerotic events are more common in people with these risk factors, but only in those populations with an average serum total cholesterol level above 3.9 mmol/l. Those most prone to having an atherosclerotic event are those who have already had such an event or who have pre-existing coronary heart disease. However, by including these as risk factors, no distinction is made between primary and secondary prevention. Atherosclerotic events of any kind, though predictive of future events are not, by definition, true risk factors and should not be viewed as such. The only absolute, unequivocal, independent atherosclerotic risk factor is an elevated serum total or, more specifically, low density lipoprotein (LDL)-cholesterol level. Whether a low level of high density lipoprotein cholesterol is an independent risk factor is not clear, but it should probably be regarded as an additive risk when the serum LDL-cholesterol is elevated.
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