Editor’s Perspective Three Reasons to Abandon Low-Density Lipoprotein Targets An Open Letter to the Adult Treatment Panel IV of the National Institutes of Health

The updated clinical guidelines for cholesterol testing and management (Adult Treatment Panel (ATP) IV) from the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults are under development and due to be published in 2012. These influential guidelines are organized and funded by the National Heart, Lung, and Blood Institute (NHLBI) and carry the imprimatur of the federal government. In this iteration, the NHLBI has a stated goal of integrating its set of Cardiovascular Risk Reduction guidelines.1 A primary focus of the previous version of the guidelines, ATP III, was a strategy of treating patients to target lowdensity lipoprotein (LDL) cholesterol levels. ATP III stated that “recent clinical trials robustly show that LDL-lowering therapy reduces risk for CHD. For these reasons, ATP III continues to identify elevated LDL cholesterol as the primary target of cholesterol-lowering therapy. As a result, the primary goals of therapy and the cutpoints for initiating treatment are stated in terms of LDL.” This reasoning, however, diverged from the clinical evidence, recommending an approach that was not tested in any clinical trial. Outcomes research promotes the need to demonstrate benefit before making recommendations for medical intervention.2,3 In that spirit, we present an open letter to the ATP IV Committee that provides the rationale for why the new guidelines should abandon the treat-to-target paradigm.