The Adult Treatment Panel III (
ATP III) of the National
Cholesterol Education Program issued an evidence-based set of guidelines on
cholesterol management in 2001. Since the publication of
ATP III, 5 major clinical trials of
statin therapy with clinical end points have been published. These trials addressed issues that were not examined in previous clinical trials of
cholesterol-lowering
therapy. The present document reviews the results of these recent trials and assesses their implications for
cholesterol management. Therapeutic lifestyle changes (TLC) remain an essential modality in clinical management. The trials confirm the benefit of
cholesterol-lowering
therapy in high-risk patients and support the
ATP III treatment goal of
low-density lipoprotein cholesterol (
LDL-C) <100 mg/dL. They support the inclusion of patients with diabetes in the high-risk category and confirm the benefits of
LDL-lowering
therapy in these patients. They further confirm that older persons benefit from therapeutic lowering of
LDL-C. The major recommendations for modifications to footnote the
ATP III treatment algorithm are the following. In high-risk persons, the recommended
LDL-C goal is <100 mg/dL, but when risk is very high, an
LDL-C goal of <70 mg/dL is a therapeutic option, ie, a reasonable clinical strategy, on the basis of available clinical trial evidence. This therapeutic option extends also to patients at very high risk who have a baseline
LDL-C <100 mg/dL. Moreover, when a high-risk patient has high
triglycerides or low
high-density lipoprotein cholesterol (HDL-C), consideration can be given to combining a
fibrate or
nicotinic acid with an
LDL-lowering drug. For moderately high-risk persons (2+ risk factors and 10-year risk 10% to 20%), the recommended
LDL-C goal is <130 mg/dL, but an
LDL-C goal <100 mg/dL is a therapeutic option on the basis of recent trial evidence. The latter option extends also to moderately high-risk persons with a baseline
LDL-C of 100 to 129 mg/dL. When
LDL-lowering
drug therapy is employed in high-risk or moderately high-risk persons, it is advised that intensity of
therapy be sufficient to achieve at least a 30% to 40% reduction in
LDL-C levels. Moreover, any person at high risk or moderately high risk who has lifestyle-related risk factors (eg,
obesity, physical inactivity, elevated
triglycerides, low HDL-C, or
metabolic syndrome) is a candidate for TLC to modify these risk factors regardless of
LDL-C level. Finally, for people in lower-risk categories, recent clinical trials do not modify the goals and cutpoints of
therapy.