The Sheffield tables are intended to guide practitioners in the prevention of primary coronary artery disease. The authors modified the Sheffield tables by (a) identifying those patients at 15% and 30% risk of coronary artery disease over 10 years and (b) using the total cholesterol to HDL cholesterol ratio rather than total cholesterol alone. Use of the tables can identify those patients who need cholesterol screening and those for whom it is unnecessary.
NOTE: The Sheffield tables are deceptively simple. To implement them is fairly complex.
Risk Group Determination
Certain factors increase the risk of coronary artery disease:
(1) hypertension (systolic blood pressure >= 140 mm Hg, OR diastolic blood pressure >= 90 mm Hg, OR current antihypertensive medication)
(2) smoking
(3) diabetes
A patient can be assigned to a risk group based on the pattern of risk factors shown.
|
Hypertension |
Smoking |
Diabetes |
Group |
|---|---|---|---|
|
No |
No |
No |
R1 |
|
No |
No |
Yes |
R2 |
|
No |
Yes |
No |
R3 |
|
No |
Yes |
Yes |
R4 |
|
Yes |
No |
No |
R5 |
|
Yes |
No |
Yes |
R6 |
|
Yes |
Yes |
No |
R7 |
|
Yes |
Yes |
Yes |
R8 |
Other Risk Considerations
Diagnoses requiring secondary prevention of coronary artery disease
(1) myocardial infarction
(2) angina pectoris
(3) peripheral vascular disease
(4) non-hemorrhagic stroke
(5) transient ischemic attacks (TIA)
(6) diabetes with microvascular complications
Hypertension classification:
(1) moderate-severe:
(1a) systolic blood pressure >= 160 mm Hg, OR
(1b) diastolic blood pressure >= 100 mm Hg
(2) mild: not moderate-severe AND
(2a) systolic hypertension 140-159 mm Hg, OR
(2b) diastolic blood pressure 90-99 mm Hg, OR
(2c) currently taking antihypertensive medication
Patient showing evidence of hypertension-related end organ damage:
(1) left ventricular hypertrophy on ECG
(2) proteinuria
(3) renal impairment
Patients where risk of primary coronary artery disease may be underestimated:
(1) patients with left ventricular hypertrophy on ECG
(2) patients with family history of premature coronary artery disease
(3) people of Asian descent living in England
(4) patients with familial hypercholesterolemia
Cholesterol Screening
People who do not need to be screened:
(1) males < 28 years of age without family history of hypercholesterolemia
(2) females < 36 years of age without family history of hypercholesterolemia
(3) males 28-40 without risk factors according to table below
(4) females 36-48 without risk factors according to table below
People who do need to be screened:
(1) males 28-40 with risk factors according to table below
(2) females 36-48 with risk factors according to table below
(3) males > 40
(4) females > 48
(5) patients with family history of hypercholesterolemia or early onset of coronary artery disease
(6) patients with need for secondary prevention
Need to Do Cholesterol Testing in Females Aged 36-48
|
Age |
R1 |
R2 |
R3 |
R4 |
R5 |
R6 |
R7 |
R8 |
|---|---|---|---|---|---|---|---|---|
|
36 |
No |
No |
No |
Yes |
No |
No |
No |
Yes |
|
38 |
No |
No |
No |
Yes |
No |
No |
No |
Yes |
|
40 |
No |
No |
No |
Yes |
No |
Yes |
Yes |
Yes |
|
42 |
No |
Yes |
Yes |
Yes |
No |
Yes |
Yes |
Yes |
|
44 |
No |
Yes |
Yes |
Yes |
No |
Yes |
Yes |
Yes |
|
48 |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
48 |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Need to Do Cholesterol Testing in Males Aged 28-40
|
Age |
R1 |
R2 |
R3 |
R4 |
R5 |
R6 |
R7 |
R8 |
|---|---|---|---|---|---|---|---|---|
|
28 |
No |
No |
No |
No |
No |
No |
No |
Yes |
|
30 |
No |
No |
No |
No |
No |
No |
No |
Yes |
|
32 |
No |
No |
No |
Yes |
No |
No |
Yes |
Yes |
|
34 |
No |
No |
No |
Yes |
No |
Yes |
Yes |
Yes |
|
36 |
No |
No |
Yes |
Yes |
No |
Yes |
Yes |
Yes |
|
38 |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
|
40 |
No |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Yes |
Cholesterol Testing
If a person needs to have serum cholesterol testing done, then 2 separate measurements are taken then averaged.
Measurements:
(1) total serum cholesterol
(2) HDL cholesterol
If HDL cholesterol cannot be measured, then an estimated value of 1.2 mmol/L is used.
total cholesterol to HDL cholesterol ratio =
= (total cholesterol) / (HDL cholesterol)
A ratio >= 8 suggests the possibility of a familial hypercholesterolemia.
average TC to HDLC ratio =
= ((ratio for first measurement) + (ratio from second measurement)) / 2
The average ratio is value used to determine risk of developing coronary artery disease in the next 10 years based on age and sex as used in the risk tables below.
Determination of Primary Risk
Risk endpoint: development of primary coronary artery disease in the next 10 years
Determinants:
(1) age
(2) sex
(3) risk factor group
(4) ratio of total cholesterol to HDL cholesterol
For patients where risk of primary coronary artery disease may be underestimated:
(1) patients with left ventricular hypertrophy on ECG: add 20 to age
(2) patients with family history of premature coronary artery disease: add 6 to age
TC-HDLC Ratios Indicting 15% Risk Levels for Females
|
Age |
R1 |
R2 |
R3 |
R4 |
R5 |
R6 |
R7 |
R8 |
|---|---|---|---|---|---|---|---|---|
|
36 |
NA |
NA |
NA |
10.2 |
NA |
NA |
NA |
8.5 |
|
38 |
NA |
NA |
NA |
8.4 |
NA |
NA |
NA |
7.0 |
|
40 |
NA |
NA |
NA |
7.1 |
NA |
10.0 |
8.7 |
5.9 |
|
42 |
NA |
10.3 |
9.0 |
6.1 |
NA |
8.6 |
7.5 |
5.1 |
|
44 |
NA |
9.1 |
7.9 |
5.4 |
NA |
7.6 |
6.6 |
4.5 |
|
46 |
NA |
8.1 |
7.1 |
4.8 |
10.0 |
6.8 |
5.9 |
4.0 |
|
48 |
NA |
7.3 |
6.4 |
4.3 |
9.0 |
6.1 |
5.3 |
3.6 |
|
50 |
9.9 |
6.7 |
5.9 |
4.0 |
8.3 |
5.6 |
4.9 |
3.3 |
|
52 |
9.2 |
6.2 |
5.4 |
3.7 |
7.7 |
5.2 |
4.5 |
3.1 |
|
54 |
8.6 |
5.8 |
5.1 |
3.5 |
7.2 |
4.9 |
4.3 |
2.9 |
|
56 |
8.1 |
5.5 |
4.8 |
3.3 |
6.8 |
4.6 |
4.0 |
2.7 |
|
58 |
7.8 |
5.3 |
4.6 |
3.1 |
6.5 |
4.4 |
3.8 |
2.6 |
|
60 |
7.4 |
5.1 |
4.4 |
3.0 |
6.2 |
4.2 |
3.7 |
2.5 |
|
62 |
7.2 |
4.9 |
4.3 |
2.9 |
6.0 |
4.1 |
3.6 |
2.4 |
|
64 |
7.0 |
4.8 |
4.2 |
2.8 |
5.9 |
4.0 |
3.5 |
2.4 |
|
66 |
6.9 |
4.7 |
4.1 |
2.8 |
5.7 |
3.9 |
3.4 |
2.3 |
|
68 |
6.8 |
4.6 |
4.0 |
2.7 |
5.7 |
3.9 |
3.4 |
2.3 |
|
70 |
6.7 |
4.6 |
4.0 |
2.7 |
5.6 |
3.8 |
3.3 |
2.3 |
where:
• NA indicates routine screening not applicable
TC-HDLC Ratios Indicting 30% Risk Levels for Females
|
Age |
R1 |
R2 |
R3 |
R4 |
R5 |
R6 |
R7 |
R8 |
|---|---|---|---|---|---|---|---|---|
|
36 |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
|
38 |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
|
40 |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
|
42 |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
9.4 |
|
44 |
NA |
NA |
NA |
9.8 |
NA |
NA |
NA |
8.2 |
|
46 |
NA |
NA |
NA |
8.8 |
NA |
NA |
NA |
7.3 |
|
48 |
NA |
NA |
NA |
7.9 |
NA |
NA |
9.8 |
6.6 |
|
50 |
NA |
NA |
NA |
7.3 |
NA |
NA |
9.0 |
6.1 |
|
52 |
NA |
NA |
9.9 |
6.8 |
NA |
9.5 |
8.3 |
5.6 |
|
54 |
NA |
NA |
9.3 |
6.3 |
NA |
8.9 |
7.8 |
5.3 |
|
56 |
NA |
10.1 |
8.8 |
6.0 |
NA |
8.4 |
7.4 |
5.0 |
|
58 |
NA |
9.6 |
8.4 |
5.7 |
NA |
8.0 |
7.0 |
4.8 |
|
60 |
NA |
9.3 |
8.1 |
5.5 |
NA |
7.7 |
6.7 |
4.6 |
|
62 |
NA |
9.0 |
7.8 |
5.3 |
NA |
7.5 |
6.5 |
4.4 |
|
64 |
NA |
8.7 |
7.6 |
5.2 |
NA |
7.3 |
6.4 |
4.3 |
|
66 |
NA |
8.5 |
7.4 |
5.1 |
NA |
7.1 |
6.2 |
4.2 |
|
68 |
NA |
8.4 |
7.3 |
5.0 |
NA |
7.0 |
6.1 |
4.2 |
|
70 |
NA |
8.3 |
7.2 |
4.9 |
10.2 |
7.0 |
6.1 |
4.1 |
TC-HDLC Ratios Indicting 15% Risk Levels for Males
|
Age |
R1 |
R2 |
R3 |
R4 |
R5 |
R6 |
R7 |
R8 |
|---|---|---|---|---|---|---|---|---|
|
28 |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
10.8 |
|
30 |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
9.4 |
|
32 |
NA |
NA |
NA |
9.8 |
NA |
NA |
10.5 |
X-8.2 |
|
34 |
NA |
NA |
NA |
8.6 |
NA |
10.6 |
9.2 |
X-7.2 |
|
36 |
NA |
NA |
9.8 |
7.7 |
NA |
9.5 |
8.2 |
X-6.4 |
|
38 |
NA |
10.1 |
8.8 |
6.9 |
10.8 |
8.5 |
7.3 |
X-5.8 |
|
40 |
NA |
9.1 |
7.9 |
6.2 |
9.7 |
7.6 |
6.6 |
X-5.2 |
|
42 |
10.5 |
8.2 |
7.2 |
5.6 |
8.8 |
6.9 |
6.0 |
4.7 |
|
44 |
9.6 |
7.5 |
6.5 |
5.1 |
8.0 |
6.3 |
5.4 |
4.3 |
|
46 |
8.7 |
6.8 |
5.9 |
4.6 |
7.3 |
5.7 |
5.0 |
3.9 |
|
48 |
8.0 |
6.3 |
5.4 |
4.3 |
6.7 |
5.2 |
4.5 |
3.6 |
|
50 |
7.3 |
5.7 |
5.0 |
3.9 |
6.1 |
4.8 |
4.2 |
3.3 |
|
52 |
6.8 |
5.3 |
4.6 |
3.6 |
5.7 |
4.4 |
3.9 |
3.0 |
|
54 |
6.3 |
4.9 |
4.3 |
3.3 |
5.2 |
4.1 |
3.6 |
2.8 |
|
56 |
5.8 |
4.6 |
4.0 |
3.1 |
4.9 |
3.8 |
3.3 |
2.6 |
|
58 |
5.4 |
4.2 |
3.7 |
2.9 |
4.5 |
3.5 |
3.1 |
2.4 |
|
60 |
5.0 |
3.9 |
3.4 |
2.7 |
4.2 |
3.3 |
2.9 |
2.2 |
|
62 |
4.7 |
3.7 |
3.2 |
2.5 |
3.9 |
3.1 |
2.7 |
2.1 |
|
64 |
4.4 |
3.5 |
3.0 |
2.4 |
3.7 |
2.9 |
2.5 |
2.0 |
|
66 |
4.1 |
3.2 |
2.8 |
2.2 |
3.5 |
2.7 |
2.4 |
2.0 |
|
68 |
3.9 |
3.0 |
2.7 |
2.1 |
3.3 |
2.6 |
2.2 |
2.0 |
|
70 |
3.7 |
2.9 |
2.5 |
2.0 |
3.1 |
2.4 |
2.1 |
2.0 |
where:
• The values in column R8 marked "X" had a data entry error in the original paper. A corrected table was subsequently published.
TC-HDLC Ratios Indicting 30% Risk Levels for Males
|
Age |
R1 |
R2 |
R3 |
R4 |
R5 |
R6 |
R7 |
R8 |
|---|---|---|---|---|---|---|---|---|
|
28 |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
|
30 |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
|
32 |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
|
34 |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
|
36 |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
|
38 |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
10.5 |
|
40 |
NA |
NA |
NA |
NA |
NA |
NA |
NA |
9.5 |
|
42 |
NA |
NA |
NA |
10.2 |
NA |
NA |
10.9 |
8.6 |
|
44 |
NA |
NA |
NA |
9.3 |
NA |
NA |
9.9 |
7.8 |
|
46 |
NA |
NA |
10.8 |
8.5 |
NA |
10.4 |
9.1 |
7.1 |
|
48 |
NA |
NA |
9.9 |
7.8 |
NA |
9.6 |
8.3 |
6.5 |
|
50 |
NA |
10.5 |
9.1 |
7.1 |
NA |
8.8 |
7.6 |
6.0 |
|
52 |
NA |
9.7 |
8.4 |
6.6 |
10.4 |
8.1 |
7.0 |
5.5 |
|
54 |
NA |
9.0 |
7.8 |
6.1 |
9.6 |
7.5 |
6.5 |
5.1 |
|
56 |
10.6 |
8.3 |
7.2 |
5.7 |
8.9 |
7.0 |
6.0 |
4.7 |
|
58 |
9.9 |
7.7 |
6.7 |
5.3 |
8.3 |
6.5 |
5.6 |
4.4 |
|
60 |
9.2 |
7.2 |
6.3 |
4.9 |
7.7 |
6.0 |
5.2 |
4.1 |
|
62 |
8.6 |
6.7 |
5.9 |
4.6 |
7.2 |
5.6 |
4.9 |
3.8 |
|
64 |
8.1 |
6.3 |
5.5 |
4.3 |
6.8 |
5.3 |
4.6 |
3.6 |
|
66 |
7.6 |
5.9 |
5.2 |
4.0 |
6.3 |
5.0 |
4.3 |
3.4 |
|
68 |
7.1 |
5.6 |
4.8 |
3.8 |
6.0 |
4.7 |
4.1 |
3.2 |
|
70 |
6.7 |
5.3 |
4.6 |
3.6 |
5.6 |
4.4 |
3.8 |
3.0 |
Treatment
There appear to be 3 separate treatment decisions incorporated into the tables:
(1) to treat with statins to lower serum cholesterol
(2) to treat with aspirin
(3) to treat hypertension
The practitioner should make a 6 month trial of diet, lifestyle change and exercise before instituting therapy targeted for primary prevention.
Decision to treat with statins to lower serum cholesterol:
(1) need for secondary prevention and serum cholesterol >= 5 mmol/L
(2) risk factors from table >= 30% and serum cholesterol >= 5 mmol/L
(3) risk of developing primary coronary artery disease >= 15%, from an risk underestimated group and serum cholesterol >= 5 mmol/L
(4) familial hypercholesterolemia and serum cholesterol >= 5 mmol/L
Consider treatment with statins to lower cholesterol:
(5) risk of developing primary coronary artery disease >= 15% and serum cholesterol >= 5 mmol/L
Decision to treat with aspirin:
(1) need for secondary prevention
(2) mild hypertension with end organ damage (left ventricular hypertrophy on ECG, proteinuria, renal impairment) or diabetes mellitus
(3) moderate-to-severe hypertension
(4) risk of developing primary coronary artery disease >= 15%
(5) familial hypercholesterolemia
NOTE: The article only mentions the use of aspirin. Since some patients have an allergy or other contraindication to the use of aspirin, I've termed this "antiplatelet agent" and added a screening question to the implementation,
Decision to treat hypertension:
(1) need for secondary prevention and mild hypertension
(2) mild hypertension with end organ damage (left ventricular hypertrophy on ECG, proteinuria, renal impairment) or diabetes mellitus
(3) moderate-to-severe hypertension
(4) risk of developing primary coronary artery disease >= 15% and mild hypertension
(5) familial hypercholesterolemia and mild hypertension
Specialty: Cardiology
ICD-10: ,
