Circulation. 2004;110:227-239
doi: 10.1161/01.CIR.0000133317.49796.0E
doi: 10.1161/01.CIR.0000133317.49796.0E
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(Circulation. 2004;110:227-239.)
© 2004 American Heart Association, Inc.
NCEP Report |
Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines
Abstract
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.
Key Words: cholesterol • trials • lipoproteins • coronary disease
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R. P. Wildman, P. Muntner, K. Reynolds, A. P. McGinn, S. Rajpathak, J. Wylie-Rosett, and M. R. Sowers The Obese Without Cardiometabolic Risk Factor Clustering and the Normal Weight With Cardiometabolic Risk Factor Clustering: Prevalence and Correlates of 2 Phenotypes Among the US Population (NHANES 1999-2004) Arch Intern Med, August 11, 2008; 168(15): 1617 - 1624. [Abstract] [Full Text] [PDF]
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D. Steinberg, C. K. Glass, and J. L. Witztum Evidence Mandating Earlier and More Aggressive Treatment of Hypercholesterolemia Circulation, August 5, 2008; 118(6): 672 - 677. [Full Text] [PDF]
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J. Shepherd, J. J. P. Kastelein, V. A. Bittner, R. Carmena, P. C. Deedwania, A. Breazna, S. Dobson, D. J. Wilson, A. L. Zuckerman, N. K. Wenger, et al. Intensive Lipid Lowering With Atorvastatin in Patients With Coronary Artery Disease, Diabetes, and Chronic Kidney Disease Mayo Clin. Proc., August 1, 2008; 83(8): 870 - 879. [Abstract] [Full Text] [PDF]
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F. A. Arain and L. T. Cooper Jr Peripheral Arterial Disease: Diagnosis and Management Mayo Clin. Proc., August 1, 2008; 83(8): 944 - 950. [Abstract] [Full Text] [PDF]
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J. Suk Danik, N. Rifai, J. E. Buring, and P. M. Ridker Lipoprotein(a), Hormone Replacement Therapy, and Risk of Future Cardiovascular Events J. Am. Coll. Cardiol., July 8, 2008; 52(2): 124 - 131. [Abstract] [Full Text] [PDF]
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J. H. Stein, C. M. Hadigan, T. T. Brown, E. Chadwick, J. Feinberg, N. Friis-Moller, A. Ganesan, M. J. Glesby, D. Hardy, R. C. Kaplan, et al. Prevention Strategies for Cardiovascular Disease in HIV-Infected Patients Circulation, July 8, 2008; 118(2): e54 - e60. [Full Text] [PDF]
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M. H. DAVIDSON Is ezetimibe/simvastatin no better than simvastatin alone? Lessons learned and clinical implications Cleveland Clinic Journal of Medicine, July 1, 2008; 75(7): 479 - 496. [Full Text] [PDF]
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 K. A. Pearce, M. M. Love, B. J. Shelton, N. E. Schoenberg, M. A. Williamson, M. A. Barron, and J. M. Houlihan Cardiovascular Risk Education and Social Support (CaRESS): Report of a Randomized Controlled Trial from the Kentucky Ambulatory Network (KAN) J Am Board Fam Med, July 1, 2008; 21(4): 269 - 281. [Abstract] [Full Text] [PDF]
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J. R. White Jr Do People With Diabetes Need Statins? The Diabetes Educator, July 1, 2008; 34(4): 664 - 673. [Abstract] [Full Text] [PDF]
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E. Roelker Screening for Coronary Artery Disease in Patients With Diabetes Diabetes Spectr, July 1, 2008; 21(3): 166 - 171. [Abstract] [Full Text] [PDF]
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K. L. Ramser, L. R. Sprabery, C. M. George, G. L. Hamann, V. A. Vallejo, C. S. Dorko, and D. A. Kuhl Physician-Pharmacist Collaboration in the Management of Patients With Diabetes Resistant to Usual Care Diabetes Spectr, July 1, 2008; 21(3): 209 - 214. [Full Text] [PDF]
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J. L. Schnipper, J. A. Linder, M. B. Palchuk, J. S. Einbinder, Q. Li, A. Postilnik, and B. Middleton "Smart Forms" in an Electronic Medical Record: Documentation-based Clinical Decision Support to Improve Disease Management J. Am. Med. Inform. Assoc., July 1, 2008; 15(4): 513 - 523. [Abstract] [Full Text] [PDF]
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M. E. Tinetti Over-the-Counter Sales of Statins and Other Drugs for Asymptomatic Conditions N. Engl. J. Med., June 19, 2008; 358(25): 2728 - 2732. [Full Text] [PDF]
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D. Mozaffarian, P. W.F. Wilson, and W. B. Kannel Beyond Established and Novel Risk Factors: Lifestyle Risk Factors for Cardiovascular Disease Circulation, June 10, 2008; 117(23): 3031 - 3038. [Full Text] [PDF]
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O. J. Liakopoulos, Y.-H. Choi, P. L. Haldenwang, J. Strauch, T. Wittwer, H. Dorge, C. Stamm, G. Wassmer, and T. Wahlers Impact of preoperative statin therapy on adverse postoperative outcomes in patients undergoing cardiac surgery: a meta-analysis of over 30 000 patients Eur. Heart J., June 2, 2008; 29(12): 1548 - 1559. [Abstract] [Full Text] [PDF]
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A. M. Wassink, Y. Van Der Graaf, S. S Soedamah-Muthu, W. Spiering, and F. L. Visseren Metabolic syndrome and incidence of type 2 diabetes in patients with manifest vascular disease Diabetes and Vascular Disease Research, June 1, 2008; 5(2): 114 - 122. [Abstract] [PDF]
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D J Hausenloy and D M Yellon Targeting residual cardiovascular risk: raising high-density lipoprotein cholesterol levels Heart, June 1, 2008; 94(6): 706 - 714. [Abstract] [Full Text] [PDF]
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 J. H.F. Rudd, K. S. Myers, S. Bansilal, J. Machac, C. A. Pinto, C. Tong, A. Rafique, R. Hargeaves, M. Farkouh, V. Fuster, et al. Atherosclerosis Inflammation Imaging with 18F-FDG PET: Carotid, Iliac, and Femoral Uptake Reproducibility, Quantification Methods, and Recommendations J. Nucl. Med., June 1, 2008; 49(6): 871 - 878. [Abstract] [Full Text] [PDF]
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R. Gupta Symptomatic Intracranial Atherosclerotic Disease: What Is the Best Treatment Option? Stroke, June 1, 2008; 39(6): 1661 - 1662. [Full Text] [PDF]
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