Treating to Cholesterol Targets in Special Populations

Dr Kwiterovich: The new NCEP [National Cholesterol Education Program] guidelines were introduced more than a year ago. Have these guidelines changed the way physicians think about preventing coronary artery disease? Dr McKenney: Yes, I believe we’ve seen a fundamental change in how physicians approach treatment. The overall prevention approach embodied in ATP [Adult Treatment Panel] I and II emphasized a “know your number” cholesterol strategy to determine the appropriate treatment. The new ATP III guideline now emphasizes a “know your risk” philosophy, and the treatment is now apportioned based on the amount of patient risk. Dr Kwiterovich: As a reminder, what specific changes in management were advocated in the new NCEP guidelines? Dr McKenney: The primary change involved the concept of “risk equivalents” in which the guidelines identify certain patients who have a future risk of coronary artery disease events equivalent to that of patients with clinical evidence of atherosclerotic disease. These risk equivalents included patients with carotid or peripheral vessel disease, who had been previously identified in ATP II, as well as all diabetic patients regardless of age and all patients with an estimated 10-year CHD [coronary heart disease] event risk of greater than 20% as determined by the ATP III Framingham-based assessment. The second substantial change involved more refined risk stratification for patients without CHD or CHD risk equivalents but with 2 risk factors. Here the guidelines call for using the ATP III Framingham chart to identify patients at the highest level of risk and, therefore, in need of the most aggressive drug therapy in addition to lifestyle modification. Dr Kwiterovich: On a practical level, have primary care physicians and internists been able to implement risk screening? Dr McKenney: It is an extra hurdle because those physicians must change their office routine and go through the algorithm, but I believe it will become more intuitive over time. Dr Kwiterovich: What about the new guidelines related to non-HDL [high-density lipoprotein] risk? ROUNDTABLE DISCUSSION