Circulation. 2002;106:3157-3160
(Circulation. 2002;106:3157.)
© 2002 American Heart Association, Inc.
I. Background and Introduction
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Introduction
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The Third Report of the Expert Panel on Detection, Evaluation,
and
Treatment of High Blood Cholesterol in Adults (Adult Treatment
Panel III, or
ATP III) presents the National Cholesterol Education
Program's (NCEP's)
updated recommendations for cholesterol testing
and management. It is similar
to Adult Treatment Panel II (ATP
II)
1,2 in general
outline and fundamental approach to therapy. It focuses
on the role of the
clinical approach to prevention of coronary
heart disease
(CHD).
* This report
continues to identify low-density
lipoprotein (LDL) as the primary target of
cholesterol-lowering
therapy. Since ATP II, a number of controlled clinical
trials
with newer cholesterol-lowering drugs have been reported. These
trials
demonstrated remarkable reductions in risk for CHD, in
both primary and
secondary prevention. Their results enrich
the evidence base upon which the
new guidelines are founded.
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1. Development of an evidence-based report
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The ATP III panel extensively analyzed the results of recent
clinical
trials whose findings strongly influenced the development
of the new
guidelines. The panel's major goals were to review
the literature objectively
and to document and display the scientific
evidence for ATP III
recommendations. Prior to the appointment
of the ATP III panel, the NCEP
Coordinating Committee developed
a list of important issues for the panel's
consideration. This
list was presented to the panel, discussed, and modified
appropriately.
The literature pertaining to each defined issue was identified
by
the panel members and by a MEDLINE search. Panel members produced
a series
of issue papers that carefully reviewed the literature;
these issue papers
became the foundation for writing the first
draft of the report. Modifications
of drafts were made following
review and discussion of additional evidence
arising from the
literature search. ATP III contains both evidence statements
and
specific recommendations based on these statements. Each evidence
statement
is qualified according to category of evidence (A—D) and
strength
of evidence (1-3), as
follows:
,
Empirical data provide the foundation for recommendations; but research in
the cholesterol field, as in almost any other, generally has addressed large
questions and has not necessarily provided answers to every specific question
of clinical intervention. Thus, in the panel's view, the general evidence
(including type and strength) often fails to carry a one-to-one correspondence
with needed specific recommendations. Consequently, ATP III recommendations
are based on the panel's best interpretation of the relation between empirical
evidence and issues of clinical intervention. The recommendations are crafted
in language that best links general evidence to specific issues; they are not
qualified quantitatively according to category and strength of evidence, which
is implicit in the language of the recommendation. Finally, for complex
issues, several evidence statements or recommendations may be grouped
together.
This evidence-based report should not be viewed as a standard of practice.
Evidence derived from empirical data can lead to generalities for guiding
practice, but such guidance need not hold for individual patients. Clinical
judgment applied to individuals can always take precedence over general
management principles. Recommendations of ATP III thus represent general
guidance that can assist in shaping clinical decisions, but they should not
override a clinician's considered judgment in the management of
individuals.
The ATP III panel played four important roles in forging this
evidence-based report. First, it systematically reviewed the literature and
judged which reports provided relevant information. Second, it synthesized the
existing literature into a series of evidence statements. This synthesis also
required a judgment as to the category and strength of evidence. Third, the
panel developed recommendations based on the evidence statements; these
recommendations represent a consensus judgment about the clinical significance
of each evidence statement. Lastly, the panel created an integrated set of
recommendations and guidelines based on individual recommendations.
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2. Features of ATP III similar to those of ATP I and II
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ATP III represents an update of recommendations for clinical
management of
high blood cholesterol and related abnormalities.
It is constructed on the
foundation of previous reports, ATP
I
3,4 and ATP
II.
1,2 The NCEP
periodically produces ATP clinical updates
as warranted by advances in the
science of cholesterol management.
Each report has a major thrust. ATP I
outlined a strategy for
primary prevention of CHD in persons with high LDL
cholesterol
(
160 mg/dL) or in those with borderline-high LDL cholesterol
(130-159
mg/dL) and multiple (2+) other risk factors. ATP II affirmed
the
importance of this approach and added a new feature: the
intensive management
of LDL cholesterol in persons with established
CHD. For CHD patients, ATP II
set a new, lower LDL-cholesterol
goal of
100 mg/dL. ATP III maintains
continuity with ATP I and
ATP II. Before considering the new constituents of
ATP III,
some of the important features shared with previous reports
are shown
in
Table I.2-1.
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3. New features of ATP III
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While ATP III maintains attention to intensive treatment of
patients with
CHD, its major new feature is a focus on primary
prevention in persons with
multiple risk factors. Many of these
persons have a relatively high risk for
CHD and will benefit
from more intensive LDL-lowering treatment than is
recommended
in ATP II.
Table
I.3-1. shows the new features of ATP III.
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4. Relation of ATP III to NCEP's public health approach
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To reduce the burden of coronary atherosclerosis in society,
LDL-cholesterol
concentrations and other CHD risk factors must be kept as near
to
an optimal level as possible through the
public health (population)
approach.
Lowering LDL-cholesterol levels in the whole population and
keeping
them low requires adoption of a low saturated fat and low cholesterol
diet,
maintenance of a healthy weight, and regular physical activity.
NCEP has
separately produced a Population Panel
Report
5,6 that
outlines
a strategy for the public health approach. The population approach
for
controlling CHD risk factors will, in the long term, have the
greatest
impact on reducing the magnitude of cardiovascular
disease in the United
States. Nonetheless, for persons in whom
LDL-cholesterol concentrations are
significantly elevated, a
clinical strategy is also required. NCEP's
recommendations for
the clinical approach are contained in the Adult Treatment
Panel
reports. The clinical and population approaches are
complementary.
7 ATP
III updates NCEP's clinical guidelines for cholesterol management.
It also
attempts to provide a bridge between clinical management
and population
strategy. Clinical professionals are integral
to the public health approach.
The clinical approach alone cannot
overcome the burden of atherosclerotic
disease in the general
population. A parallel and simultaneous effort must be
made
to promote changes in population life habits to retard atherogenesis.
The
clinical approach can, however, delay or prevent the onset
of CHD and prolong
the lives of many persons at increased risk.
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5. Relation of ATP III to other clinical guidelines
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Since the publication of ATP II, other bodies have published
guidelines for
CHD risk reduction. For persons with established
CHD, ATP III recommendations
largely match other guidelines.
Recent clinical trials confer a strong
scientific base for the
benefit of cholesterol-lowering therapy in secondary
prevention,
making it easier to achieve common ground with other guidelines.
There
is less congruence on guidelines for primary prevention through
clinical
therapy. Several recent guidelines place almost exclusive
priority for
treatment on persons at high risk in the short
term, (i.e.,
10 years).
This priority is dictated largely by
cost considerations, particularly the
costs of cholesterol-lowering
drugs. ATP III likewise identifies individuals
at high short-term
risk who need intensive intervention. However, an important
feature
of the ATP III guidelines (as in ATP I and ATP II) is extension
of the
clinical approach to the reduction of long-term (i.e.,
>10-year) risk. By
so doing, ATP III links clinical therapy
to the public health approach and
goes beyond the more restrictive
recommendations of some guideline committees.
The panel concluded
that clinical guidelines should not be truncated to
include
only persons at high short-term risk. High serum cholesterol
itself is
a major cause of the build-up of coronary atherosclerosis,
and hence of the
development of CHD in the long term. For this
reason, ATP III stresses the
need for long-term prevention of
coronary atherosclerosis, as well as
short-term prevention of
acute coronary syndromes resulting from advanced
atherosclerosis.
A comment is required about the relationship of ATP III to what is commonly
called global risk assessment for CHD. In recent clinical guidelines,
assessment of absolute risk (global risk) for experiencing acute coronary
syndromes over the short term (10 years) has assumed increasing importance
for primary prevention. These estimates provide a guide for selecting persons
for clinical intervention. Accordingly, ATP III can be considered the
"cholesterol component" of integrated, short-term risk reduction.
At the same time, ATP III can be viewed as a broad-based approach to reducing
CHD risk through short-term and long-term control of high serum cholesterol
and related disorders of lipid and lipoprotein metabolism. Thus, on the one
hand, high serum cholesterol can be identified in the context of global risk
assessment that employs all other risk factors. Alternatively, risk assessment
can be performed for persons in whom high serum cholesterol and related lipid
disorders are detected independently. Thus, ATP III guidelines are designed to
be flexible for use in various approaches to primary prevention.
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Footnotes
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* In ATP III, CHD is defined as symptomatic ischemic heart disease,
including
myocardial infarction, stable or unstable angina,
demonstrated myocardial
ischemia by noninvasive testing, and
history of coronary artery
procedures.
Related Article:
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References
Circulation 2002 106: 3373-3421.
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Introduction
1. Development of an...