Updated Guidelines for Cholesterol Management

DURING THE PAST DECADE, THERE HAS BEEN TREMENdous progress in identifying novel risk factors and precisely delineating the role of traditional risk factors associated with coronary heart disease (CHD), with substantial research advances related to the role of lipoproteinsandlipidmetabolism.Observationalstudieshaveestablished the relationship of serum cholesterol and other lipoproteins with CHD in specific subgroups. Clinical trials have demonstrated convincing benefits of cholesterol lowering for reducing death and myocardial infarction among patients with CHD as well as beneficial effects of cholesterol lowering for decreasing the incidence of cardiac events in patients without established coronary disease. Accurately synthesizing and appropriatelyapplying this rapidlyaccumulatingevidence into clinicalpractice isessential for reducingthemorbidityandmortality associated with coronary disease. Thus, the Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel (Adult Treatment Panel III [ATP III]) published in this issue of THE JOURNAL is most welcome. The NCEP expert panel, a multidisciplinary group that includes leading clinicians and researchers, provides a detailed summary of updated clinical guidelines for the detection, evaluation, and management of high blood cholesterol in adults. The Executive Summary is based on the comprehensive ATP III document, a more than 200-page detailed report that includes numerous tables and over 800 references, and in which the NCEP panel thoroughly evaluates current scientific information on cholesterol, applies a rigorous evidencebased framework, and carefully outlines the clinical and scientific rationale for the guidelines and recommendations. The marked increase in new information on lipoproteins thathasbecomeavailablesincepublicationofAdultTreatment Panel II in1993 has resulted inmanynewand important features in ATP III. Although the authors summarize some of the new features of the updated guidelines (in their Table 1), several aspects of the ATP III Report deserve special mention. First, among patients without clinical coronary disease, emphasis is placed on prospectively estimating absolute risk. Most clinical research literature reports relative risks with statements such as, “Patients with finding X were Y times more likely to have an event than patients without finding X.” Although this information is helpful, it is an important step away from actual clinical practice. Real physicians caring for real patients care about real, that is, absolute, risk. The important clinical question is, “What is this patient’s actual likelihood for developing disease?” In ATP III, patients with an absolute 10-year risk of .20% for developing clinical coronary disease are considered candidates for very aggressive therapy. This includes a lowdensity lipoprotein (LDL) cholesterol treatment goal of ,100 mg/dL and a recommendation to initiate drug therapy at an LDL level of .130 mg/dL. Patients with diabetes are also considered candidates for aggressive therapy, whether or not clinical coronary disease is present, because their absolute risk for major events is also very high. For patients with an estimated absolute risk of 10%-20%, somewhat less aggressive therapy is recommended, although the guidelines do suggest pharmacotherapy if needed to keep LDL levels ,130 mg/dL. To calculate absolute risk for developing new coronary disease, the ATP III Report presents a modification of the Framingham Risk Prediction Score. The scheme presented is slightly, but importantly, different from a previously published version in that it does not include diabetes, because diabetes is now considered a CHD equivalent rather than a risk factor. The scheme takes into account important interactions of age with smoking, age with total cholesterol, and systolic blood pressure with treatment. Despite the sophistication of the sex-specific models, these risk prediction–scoring instruments should be easy to incorporate into clinical practice. A second important feature of the ATP III Executive Summary is the inclusion of lipid abnormalities that go beyond elevated LDL cholesterol. The metabolic syndrome is a recently recognized constellation of findings thought to arise from insulin resistance and includes hypertension, abdominal obesity, hyperglycemia, elevated triglyceride levels, and low levels of high-density lipoprotein (HDL) cholesterol. Specific recommendations for treatment include weight control, physical activity, and a seemingly paradoxi-