Author + information
- Scott M. Grundy,
- James I. Cleeman,
- C. Noel Bairey Merz,
- H. Bryan Brewer Jr,
- Luther T. Clark,
- Donald B. Hunninghake⁎,
- Richard C. Pasternak,
- Sidney C. Smith Jr,
- Neil J. Stone,
- Coordinating Committee of the National Cholesterol Education Program
The Adult Treatment Panel III (ATP III) of the National Cholesterol Education Program issued an evidence-based set of guidelines on cholesterol management in 2001. Since the publication of ATP III, 5 major clinical trials of statin therapy with clinical end points have been published. These trials addressed issues that were not examined in previous clinical trials of cholesterol-lowering therapy. The present document reviews the results of these recent trials and assesses their implications for cholesterol management. Therapeutic lifestyle changes (TLC) remain an essential modality in clinical management. The trials confirm the benefit of cholesterol-lowering therapy in high-risk patients and support the ATP III treatment goal of low-density lipoprotein cholesterol (LDL-C) <100 mg/dL. They support the inclusion of patients with diabetes in the high-risk category and confirm the benefits of LDL-lowering therapy in these patients. They further confirm that older persons benefit from therapeutic lowering of LDL-C. The major recommendations for modifications to footnote the ATP III treatment algorithm are the following. In high-risk persons, the recommended LDL-C goal is <100 mg/dL, but when risk is very high, an LDL-C goal of <70 mg/dL is a therapeutic option, ie, a reasonable clinical strategy, on the basis of available clinical trial evidence. This therapeutic option extends also to patients at very high risk who have a baseline LDL-C <100 mg/dL. Moreover, when a high-risk patient has high triglycerides or low high-density lipoprotein cholesterol (HDL-C), consideration can be given to combining a fibrate or nicotinic acid with an LDL-lowering drug. For moderately high-risk persons (2+ risk factors and 10-year risk 10% to 20%), the recommended LDL-C goal is <130 mg/dL, but an LDL-C goal <100 mg/dL is a therapeutic option on the basis of recent trial evidence. The latter option extends also to moderately high-risk persons with a baseline LDL-C of 100 to 129 mg/dL. When LDL-lowering drug therapy is employed in high-risk or moderately high-risk persons, it is advised that intensity of therapy be sufficient to achieve at least a 30% to 40% reduction in LDL-C levels. Moreover, any person at high risk or moderately high risk who has lifestyle-related risk factors (eg, obesity, physical inactivity, elevated triglycerides, low HDL-C, or metabolic syndrome) is a candidate for TLC to modify these risk factors regardless of LDL-C level. Finally, for people in lower-risk categories, recent clinical trials do not modify the goals and cutpoints of therapy.
↵⁎ Member of the Working Group until December 31, 2003.
This statement was approved by the National Heart, Lung, and Blood Institute in April 2004, by the American Heart Association Science Advisory and Coordinating Committee in May 2004, and by the American College of Cardiology Foundation Board of Trustees in May 2004. A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0292. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 410-528-4121, fax 410-528-4264, or e-mail. To make photocopies for personal or educational use, call the Copyright Clearance Center, 978-750-8400.
- American College of Cardiology Foundation
- Review of Recent Clinical Trials With Major Cardiovascular End points
- Lipid Targets of Therapy
- Relation of Serum LDL-C Concentrations to CHD Risk
- Relation of Percentage Reduction in LDL to CHD Risk: Implications for Therapy
- Implications of HPS and PROVE IT for Clinical Management of Elevated LDL-C in High-Risk Patients
- Implications of HPS Results for Patients With Diabetes
- Implications of the ASCOT-LLA and ALLHAT-LLT Trials for Patients at Moderately High Risk
- Summary of Implications of Recent Clinical Trials for ATP III Treatment Algorithm