Circulation. 2004;110:227-239
doi: 10.1161/01.CIR.0000133317.49796.0E
doi: 10.1161/01.CIR.0000133317.49796.0E
(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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 D. M. Nathan, J. B. Buse, M. B. Davidson, E. Ferrannini, R. R. Holman, R. Sherwin, and B. Zinman Medical Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy: A consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes Diabetes Spectr, January 1, 2009; 22(1): 6 - 17. [Full Text] [PDF]
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E. S. Spatz, M. E. Canavan, and M. M. Desai From Here to JUPITER: Identifying New Patients for Statin Therapy Using Data From the 1999-2004 National Health and Nutrition Examination Survey Circ Cardiovasc Qual Outcomes, January 1, 2009; 2(1): 41 - 48. [Abstract] [Full Text] [PDF]
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 K. M. Johnson, D. A. Dowe, and J. A. Brink Traditional Clinical Risk Assessment Tools Do Not Accurately Predict Coronary Atherosclerotic Plaque Burden: A CT Angiography Study Am. J. Roentgenol., January 1, 2009; 192(1): 235 - 243. [Abstract] [Full Text] [PDF]
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D. M. Nathan, J. B. Buse, M. B. Davidson, E. Ferrannini, R. R. Holman, R. Sherwin, and B. Zinman Medical Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy: A consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes Diabetes Care, January 1, 2009; 32(1): 193 - 203. [Abstract] [Full Text] [PDF]
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American Diabetes Association Standards of Medical Care in Diabetes--2009 Diabetes Care, January 1, 2009; 32(Supplement_1): S13 - S61. [Full Text] [PDF]
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E. A. Stein Additional Lipid Lowering Trials Using Surrogate Measurements of Atherosclerosis by Carotid Intima-Media Thickness: More Clarity or Confusion? J. Am. Coll. Cardiol., December 16, 2008; 52(25): 2206 - 2209. [Full Text] [PDF]
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 S. I. Rennard Lessons from Multidisciplinary Cross-Fertilization: Chronic Obstructive Pulmonary Disease, Lung Cancer, and Heart Disease Proceedings of the ATS, December 1, 2008; 5(8): 865 - 868. [Abstract] [Full Text] [PDF]
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 M.-A. Cornier, D. Dabelea, T. L. Hernandez, R. C. Lindstrom, A. J. Steig, N. R. Stob, R. E. Van Pelt, H. Wang, and R. H. Eckel The Metabolic Syndrome Endocr. Rev., December 1, 2008; 29(7): 777 - 822. [Abstract] [Full Text] [PDF]
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D. Voora, S. H. Shah, C. R. Reed, J. Zhai, D. R. Crosslin, C. Messer, B. A. Salisbury, and G. S. Ginsburg Pharmacogenetic Predictors of Statin-Mediated Low-Density Lipoprotein Cholesterol Reduction and Dose Response Circ Cardiovasc Genet, December 1, 2008; 1(2): 100 - 106. [Abstract] [Full Text] [PDF]
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R. A. Krasuski Primary Prevention and Statins: Is It Just About Going to Class? Mayo Clin. Proc., December 1, 2008; 83(12): 1313 - 1315. [Full Text] [PDF]
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T. A. Jacobson, D. A. Wertz, T. Hoy, A. Kuznik, D. Grochulski, and M. Cziraky Comparison of Cardiovascular Event Rates in Patients Without Cardiovascular Disease in Whom Atorvastatin or Simvastatin Was Newly Initiated Mayo Clin. Proc., December 1, 2008; 83(12): 1316 - 1325. [Abstract] [Full Text] [PDF]
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H. Sillesen, P. Amarenco, M. G. Hennerici, A. Callahan, L. B. Goldstein, J. Zivin, M. Messig, K. M. Welch, and on Behalf of the SPARCL Investigators Atorvastatin Reduces the Risk of Cardiovascular Events in Patients With Carotid Atherosclerosis: A Secondary Analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Trial Stroke, December 1, 2008; 39(12): 3297 - 3302. [Abstract] [Full Text] [PDF]
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P. M Ridker, N. P. Paynter, N. Rifai, J. M. Gaziano, and N. R. Cook C-Reactive Protein and Parental History Improve Global Cardiovascular Risk Prediction: The Reynolds Risk Score for Men Circulation, November 25, 2008; 118(22): 2243 - 2251. [Abstract] [Full Text] [PDF]
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P. M Ridker, E. Danielson, F. A.H. Fonseca, J. Genest, A. M. Gotto Jr., J. J.P. Kastelein, W. Koenig, P. Libby, A. J. Lorenzatti, J. G. MacFadyen, et al. Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein N. Engl. J. Med., November 20, 2008; 359(21): 2195 - 2207. [Abstract] [Full Text] [PDF]
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 M. Joras and P. Poredos The association of acute exercise-induced ischaemia with systemic vasodilator function in patients with peripheral arterial disease Vascular Medicine, November 1, 2008; 13(4): 255 - 262. [Abstract] [PDF]
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 H. Y. Tomoum, M. M. Awadallah, D. A. Fouad, and A. H. Ali Lipid Profile, Apolipoproteins A and B in Children With Epilepsy J Child Neurol, November 1, 2008; 23(11): 1275 - 1281. [Abstract] [PDF]
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D J Hausenloy and D M Yellon Targeting residual cardiovascular risk: raising high-density lipoprotein cholesterol levels Postgrad. Med. J., November 1, 2008; 84(997): 590 - 598. [Abstract] [Full Text] [PDF]
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A. Kulik, M. A. Brookhart, R. Levin, M. Ruel, D. H. Solomon, and N. K. Choudhry Impact of Statin Use on Outcomes After Coronary Artery Bypass Graft Surgery Circulation, October 28, 2008; 118(18): 1785 - 1792. [Abstract] [Full Text] [PDF]
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 M. T. Roe, F.-S. Ou, K. P. Alexander, L. K. Newby, J. M. Foody, W. B. Gibler, W. E. Boden, E. M. Ohman, S. C. Smith Jr, and E. D. Peterson Patterns and prognostic implications of low high-density lipoprotein levels in patients with non-ST-segment elevation acute coronary syndromes Eur. Heart J., October 2, 2008; 29(20): 2480 - 2488. [Abstract] [Full Text] [PDF]
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 N. Sood, W. L Baker, and C. I Coleman Effect of glucomannan on plasma lipid and glucose concentrations, body weight, and blood pressure: systematic review and meta-analysis Am. J. Clinical Nutrition, October 1, 2008; 88(4): 1167 - 1175. [Abstract] [Full Text] [PDF]
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 J. Odom, B. Williamson, and L. Carter Rosiglitazone and pioglitazone in the treatment of diabetes mellitus Am. J. Health Syst. Pharm., October 1, 2008; 65(19): 1846 - 1850. [Full Text] [PDF]
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E. L. Johnson, J. D. Brosseau, M. Soule, and J. Kolberg Treatment of Diabetes in Long-Term Care Facilities: A Primary Care Approach Clin. Diabetes, October 1, 2008; 26(4): 152 - 156. [Abstract] [Full Text] [PDF]
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 L. G. Mikael and R. Rozen Homocysteine modulates the effect of simvastatin on expression of ApoA-I and NF-{kappa}B/iNOS Cardiovasc Res, October 1, 2008; 80(1): 151 - 158. [Abstract] [Full Text] [PDF]
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W. E. Cayley Monitoring Cholesterol Levels: Understanding Variance and Finding the Most Useful Data Ann Intern Med, September 16, 2008; 149(6): 436 - 437. [Full Text] [PDF]
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R. R. Giraldez, R. P. Giugliano, S. Mohanavelu, S. A. Murphy, C. H. McCabe, C. P. Cannon, and E. Braunwald Baseline Low-Density Lipoprotein Cholesterol Is an Important Predictor of the Benefit of Intensive Lipid-Lowering Therapy: A PROVE IT-TIMI 22 (Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis In Myocardial Infarction 22) Analysis J. Am. Coll. Cardiol., September 9, 2008; 52(11): 914 - 920. [Abstract] [Full Text] [PDF]
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