The National Cholesterol Education Program (NCEP) has updated their Adult Treatment Panel (ATP) III guidelines with evidence derived from recent statin trials and published them in the July 12 rapid issue of Circulation.

The updated recommendations, which are endorsed by The National Heart, Lung, and Blood Institute, the American College of Cardiology, and the American Heart Association, suggest that more intensive cholesterol treatment is an option for people at high risk for myocardial infarction (MI) and cardiovascular death.

"The lower the better for high-risk people," ATP III chair Scott Grundy, MD, PhD, who is also the American Heart Association's representative to the NCEP, says in a news release. "That's the message on ... low-density lipoprotein (LDL) cholesterol from recent clinical trials."

To update ATP III guidelines published in 2001, the NCEP panel reviewed five major clinical trials of statins. Individuals at high risk were defined as those with more than a 20% estimated risk of MI or cardiac death within 10 years based on history of MI, angina, previous angioplasty or bypass surgery, stenotic vessels to the extremities or brain, or diabetes.

The 2001 guidelines recommended addressing risk factors related to lifestyle, such as obesity and lack of physical activity, as well as treatment with cholesterol-lowering agents for high-risk individuals with LDL-cholesterol levels of at least 130 mg/dL to reduce LDL cholesterol to target levels of less than 100 mg/dL.

"For people with LDL cholesterol levels of 100-129 mg/dL, use of cholesterol-lowering drugs was a therapeutic option based on clinical judgment," Dr. Grundy says. "The updated recommendations call for drug therapy in almost all high-risk patients with LDL cholesterol of 100 mg/dL or higher."

The updated guidelines preserve the same general goal of cholesterol-lowering treatment for high-risk individuals as in the 2001 guidelines. However, to reduce LDL-cholesterol levels to less than 100 mg/dL, an LDL goal of less than 70 mg/dL is a therapeutic option for people at very high risk of MI or death. Very high risk individuals are those with cardiovascular disease plus diabetes, persistent cigarette smoking, poorly controlled hypertension, or multiple risk factors of the metabolic syndrome (high triglycerides, low levels of high density lipoprotein [HDL] cholesterol, obesity), and those who recently had an MI.
Moderately high risk individuals are defined as those with multiple risk factors and an estimated 10% to 20% risk of MI or cardiac death within 10 years. These individuals should be treated if LDL-cholesterol levels are 130 mg/dL or higher, whereas drug therapy is optional if levels are between 100 to 129 mg/dL.

Goals for drug therapy in individuals at high or moderately high risk should be a 30% to 40% reduction in LDL-cholesterol levels. Recommendations for treating individuals at low or moderate risk are unchanged from the 2001 guidelines. Evidence from the recent statin trials supports treatment, when indicated, regardless of age, as interventions to lower cholesterol levels are often effective and justified even in older individuals.
"There is strong suggestive evidence that lower LDL cholesterol is better, but it has to be balanced against the cost and side effects of achieving very low levels, which often requires high doses of medication or combination therapy," Dr. Grundy says. "The idea that you can use cholesterol-lowering drugs without lifestyle changes is incorrect. Lifestyle changes have enormous benefits beyond lowering LDL cholesterol, such as raising levels of good cholesterol, lowering triglycerides, improving diabetes, and reducing inflammation."

These guidelines will be updated further based on the results of ongoing clinical trials scheduled for completion in the next 18 months. Circulation.

Source: Diabetes In Control.com.