New Cholesterol Treatment Guidelines:
ATP III Guideline Summary of Updates

By Ronald Goldberg, MD

The Adult Treatment Panel III (ATP III) of the National Cholesterol Education Program released updated guidelines on the treatment of cholesterol management on Monday, July 12, 2004 in Circulation: Journal of the American Heart Association. The updated guidelines review the results of 5 major clinical trials that have been released since the publication of ATP III in 2001. The following is a summary of the updated guidelines for patients, which are summarized in bold type.

High-Risk and Very High-Risk

High-risk individuals are those previously defined in the original NCEP ATP III guidelines who have already developed coronary heart disease or have obstructions of cerebral (brain) and peripheral (leg) blood vessels. In addition, individuals with diabetes and older subjects with no diabetes or known vascular disease but who have multiple risk factors may have equivalent high risk. Very high-risk individuals are a subgroup of these individuals defined in the update that includes people who have had a heart attack, stroke or peripheral circulatory disease and in addition have multiple major risk factors - particularly if they are severe or poorly controlled, especially diabetes and smoking, or if they in addition have the metabolic syndrome (high triglycerides and low HDL) or an acute coronary syndrome - development of unstable angina that could lead to a heart attack.

Treatment: LDL-C goal for very high-risk people is at the lowest yet, with a recommended LDL-C goal of <70mg/dL, as opposed to the previously set target of <100 mg/dL for all high-risk individuals. The new guidelines also recommend that very high risk patients who have already reached a baseline LDL-C<100mg/dL may be treated to a lower goal of an LDL-C <70mg/dL. The update lowered the cutpoint for LDL-C lowering drug treatment in all high-risk individuals from >130 mg/dl down to >100 mg/dl. Additionally, for high-risk patients who also have high triglycerides or low HDL cholesterol, combining a fibrate or nicotinic acid with an LDL-lowering drug may be considered, rather than using them as alternatives to statins in those with LDL-cholesterol <130 mg/dl as originally recommended in ATP-III. A goal of 30 to 40 percent reduction in LDL cholesterol should be set if drug therapy is chosen.

Moderate risk

The original NCEP ATP III guidelines defined moderate risk as that present in individuals without any known vascular disease, but with at least 2 major risk factors. Risk factors include: cigarette smoking, hypertension, low HDL cholesterol, family history of premature coronary heart disease, and age (men, age 45 or older; women, age 55 or older). They recommended that a quantification of risk of heart attack be performed using the Framingham Scoring System. If the score was >20% risk within 10 years they should be considered at high risk and treatment instituted as described above. If the score was 10-20% this was called intermediate risk. This has now been redefined as "moderately high risk."

Treatment: The original ATP III guidelines advised dietary treatment for all moderate risk individuals at an LDL cholesterol >130 mg/dl. They also recommended drug therapy for LDL- levels >160 mg/dl except for those with moderately high risk, where treatment should be introduced at an LDL cholesterol of 130 mg/dl. The new guidelines endorse these recommendations and additionally suggest an alternative option of initiating pharmacotherapy between 100-129 mg/dl in selected subjects in this category, e.g. older subjects with more than 2 risk factors, severe risk factors, metabolic syndrome, or the presence of emerging risk factors e.g. CRP >3 or coronary calcium > 75th percentile. Once again, a goal of 30 to 40 percent reduction in LDL cholesterol should be set if drug therapy is chosen for moderately high-risk patients.

Low Risk

ATP III guidelines for treatment at low risk have not changed.

Elderly

Evidence from new trials suggests that elderly people benefit from lowering LDL-C also.