In July 2004 the Coordinating Committee of the National Cholesterol Education Program published an update to its 2001 Adult Treatment Panel (ATP) III Guidelines.1 This update was based on evidence obtained from the examination of five major clinical trials of statin therapy: the Heart Protection Study (HPS); the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER); the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial-Lipid-Lowering Trial (ALLHAT-LLT); the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid-Lowering Arm (ASCOT-LLA); and the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 (PROVE IT-TIMI22) trial. These trials confirmed the benefits of achieving a low-density lipoprotein cholesterol (LDL-C) < 70 mg/dL in "very high risk patients," defined as those with coronary heart disease (CHD) and one or more of the following: diabetes, multiple risk factors, acute coronary syndrome, smoking and/or metabolic syndrome.
The July 2004 report highlights and reaffirms the importance of nutrition and lifestyle and supports all previous guideline recommendations in these important areas. It emphasizes that any patient at high or moderately high risk who has lifestyle risk factors such as obesity or physical inactivity be instructed in therapeutic lifestyle changes (TLC) regardless of his or her baseline LDL-C. In addition, based on the PROSPER trial, the report reaffirms the benefit of LDL-C lowering in the older adult population.
The 2004 report supports previous recommendations that LDL-C remain the number one target of therapy in patients at all levels of risk. The report reaffirms the benefit of LDL-C lowering in high-risk individuals as well as in those with a Framingham Risk score > 20% to an LDL-C goal <=100 mg/dL. However, in those considered very high risk patients (established CHD plus one or more additional risk factors such as smoking, diabetes, metabolic syndrome, or acute coronary syndrome), the optional goal of < 70 mg/dL should be considered. This option even includes those at "very high risk" who have a baseline LDL-C of less than 100 mg/dL. For patients with moderately high risk (more than two risk factors and 10-year risk 10 > -20%), the LDL-C goal remains < 130 mg/dL, but a goal of < 100 mg/dL is a therapeutic option (Table 1).
When considering therapeutic options for patients at risk for cardiovascular disease (CVD), it is important that lifestyle changes remain the cornerstone of therapy. Understanding each patient's level of risk facilitates setting goals for therapy that are appropriate and reasonable. When an LDL-lowering medication is chosen for patients at high or moderately high risk, the new recommendations clearly state that an LDL-reduction of at least 30% to 40% be achieved, if possible. For those patients at low risk, no changes in the guidelines have been recommended.
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