Cholesterol Treatment Guidelines Update -- American Family Physician

www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 871 1988, the National Cholesterol Education Program, Adult Treatment Panel I (NCEP–ATP I) developed its first set of guidelines, establishing clear goals for patients with lipid abnormalities. In 1993, the NCEP–ATP II revised its initial recommendations and developed a second set of guidelines; in addition to emphasizing CHD risk status, this report placed even more emphasis on HDL levels, weight loss, and physical activity. In May 2001, the NCEP–ATP III released its third set of guidelines, reflecting changes in calculating coronary risk and in the management of hypercholesterolemia. According to the new guidelines, the number of patients with cholesterol levels that can be classified as abnormal has now tripled. The NCEP–ATP III guidelines are similar to those in the second report in identifying LDL as a primary target of cholesterol-lowering therapy. Risk stratification continues to determine LDL goals and the intensity of LDL-lowering therapy. Dietary therapy remains the first line of treatment, with drug therapy reserved for use in patients at high risk for CHD or patients who do not respond C oronary heart disease (CHD) is the leading cause of morbidity and mortality in the United States, accounting for approximately 500,000 deaths per year and an associated annual morbidity cost of more than $200 billion. In the past three decades, numerous clinical and epidemiologic studies have shown repeatedly that an elevated blood cholesterol level is one of the major modifiable risk factors associated with the development of CHD. In particular, these studies have demonstrated that low-density lipoprotein (LDL) cholesterol is the primary lipoprotein mediating atherosclerosis. Other risk factors such as cigarette smoking, hypertension, diabetes, and a low level of high-density lipoprotein (HDL) cholesterol also have been implicated in CHD. In an effort to address this public health issue, the National Institutes of Health established the National Cholesterol Education Program in 1985. In Hypercholesterolemia is one of the major contributors to atherosclerosis and coronary heart disease in our society. The National Cholesterol Education Program of the National Institutes of Health has created a set of guidelines that standardize the clinical assessment and management of hypercholesterolemia for practicing physicians and other professionals in the medical community. In May 2001, the National Cholesterol Education Program released its third set of guidelines, reflecting changes in cholesterol management since their previous report in 1993. In addition to modifying current strategies of risk assessment, the new guidelines stress the importance of an aggressive therapeutic approach in the management of hypercholesterolemia. The major risk factors that modify low-density lipoprotein goals include age, smoking status, hypertension, high-density lipoprotein levels, and family history. The concept of “CHD equivalent” is introduced—conditions requiring the same vigilance used in patients with coronary heart disease. Patients with diabetes and those with a 10-year cardiac event risk of 20 percent or greater are considered CHD equivalents. Once lowdensity lipoprotein cholesterol is at an accepted level, physicians are advised to address the metabolic syndrome and hypertriglyceridemia. (Am Fam Physician 2002;65:871-80. Copyright© 2002 American Academy of Family Physicians.) Cholesterol Treatment Guidelines Update