Professional Documents
Culture Documents
The National Cholesterol Education Program Adult Treatment Panel III Guidelines
The National Cholesterol Education Program Adult Treatment Panel III Guidelines
The treatment
approach involves therapeutic lifestyle
changes with diet, exercise, and weight
loss. It requires regular, careful moni-
toring of serum cholesterol levels. The The National Cholesterol Education
new ATP III guidelines expand greatly Program Adult Treatment Panel III
the total number of patients who are eli- guidelines
gible for treatment of hypercholes-
terolemia. Definite goals for LDL-C are
defined for patients with coronary heart Michael B. Clearfield, DO
disease and patients at risk for subse-
quent clinical events. Many, if not most
of these patients, will not be able to
achieve their target LDL-C level without
pharmacologic therapy.
The ATP III evidence-based guide- Coronary heart disease (CHD) remains the leading cause of death in the United
lines have defined the standard. It is our States with more than 40% of all deaths each year directly attributed to the
responsibility and unique opportunity disease. Current evidence suggests that early identification and aggressive
to fulfill these expectations through modification of risk factors offer the most promising approach to reducing
thoughtful clinical practice. We might the burden of CHD. Dyslipidemia has been identified as the primary risk
consider this supplement to represent a factor leading to the development of CHD. It is estimated that nearly 65 mil-
tool to help us accomplish this task. lion Americans require some form of lipid-modification therapy.
The National Cholesterol Education Program Adult Treatment Panel III
References (NCEP ATP III) set of guidelines released in May 2001 provides physicians with
1. Expert Panel on the Detection, Evaluation, and evidence-based recommendations on the classification, diagnosis, and treatment
Treatment of High Blood Cholesterol in Adults.
Executive Summary of the Third Report of the of lipid disorders. New features of the guidelines include a scoring system
National Cholesterol Education Program (NCEP) for calculating CHD risk, as well as the identification of CHD risk equiva-
Expert Panel on Detection, Evaluation and Treat- lents, lower treatment target goals, and an emphasis on conditions conferring
ment of High Blood Cholesterol in Adults (Adult
Treatment Panel III). JAMA. 2001;285:2486-2497. a higher risk for CHD, such as the metabolic syndrome. The ATP III emphasis
on risk assessment substantially increases the number of patients considered
2. The American Heart Association 2002 Heart at risk for CHD and will expand the number eligible for lifestyle and drug inter-
and Stroke Statistical Update. Dallas, Tex: American
Heart Association; 2001; pp 4-23. ventions.
This article highlights the new recommendations and reviews the impact
3. Pearson TA, Laurora I, Chu H, Kafonek S. The
Lipid Treatment Assessment Project (L-TAP): A
of ATP III on osteopathic physicians.
multicenter survey to evaluate the percentages (Key words: atherosclerosis, cholesterol, coronary heart disease, dyslipi-
of dyslipidemic patients receiving lipid-lowering demia, low-density lipoprotein cholesterol [LDL-C])
therapy and achieving low-density lipoprotein
cholesterol goals. Arch Intern Med. 2000;160:459-
467.
Clearfield • The National Cholesterol Education Program Adult Treatment Panel III guidelines JAOA • Supplement 1 • Vol 103 • No 1 • January 2003 • S1
S2 • JAOA • Supplement 1 • Vol 103 • No 1 • January 2003 Clearfield • The National Cholesterol Education Program Adult Treatment Panel III guidelines
Pharmacologic therapy
Although ATP III emphasizes the impor-
Treatment goal level tance of nonpharmacologic therapy, it
Risk stratification (low-density lipoprotein recognizes limitations of such therapy
cholesterol)
and encourages the addition of drug
therapy if TLC fails to move a patient to
goal after 3 months. High-risk patients
will most likely require drug therapy
High risk of coronary heart
disease (CHD) along with TLC from the onset of treat-
100 mg/dL ment. As stated earlier, treatment goals
(documented CHD or CHD
risk equivalent) and lipid thresholds for initiating drug
therapy are based on the patient’s degree
of risk.
For patients with the highest risk for
Moderate (two or more risk
coronary events, the LDL-C threshold
130 mg/dL for initiation of therapy is greater than
factors)
or equal to 130 mg/dL (after a 3-month
trial of TLC) and the goal is less than
100 mg/dL. For patients with LDL-C
between 100 mg/dL and 129 mg/dL,
drug therapy is optional and physicians
Low (zero to one risk factor) 160 mg/dL are encouraged to use their professional
clinical judgment to determine the nature
of therapy required to reduce CHD risk.
For patients with moderate risk
Figure 2. Low-density lipoprotein cholesterol goals according to risk factor stratification. without definite CHD or CHD risk
(Source: Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood
equivalents but with more than two
Cholesterol in Adults (Adult Treatment Panel III) Full Report. Available at: http://www.nhlbi.
major risk factors and a 10-year risk of
nih.gov/guidelines/cholesterol/atp3_rpt.htm. Accessed December 2, 2002.)
10% to 20%, the threshold is greater than
or equal to 130 mg/dL and the target is
sufficient to enable them to achieve an Therapeutic lifestyle changes also less than 130 mg/dL.
LDL-C target level of less than First-line therapy for all patients is TLC For patients at moderate risk but with
130 mg/dL. Patients at the lowest risk and may be substantial enough in groups a 10-year risk of less than 10%, the
are those with one or fewer major risk at lower risk to reach their LDL-C goals. threshold for LDL-C is greater than or
factors. In all but rare cases, these indi- Components of TLC that have demon- equal to 160 mg/dL and the target is less
viduals have a 10-year risk of less than strated effectiveness in lowering LDL-C than 130 mg/dL. For patients without
10%. The target LDL-C level in this group include eating a healthy diet, regular CHD and with zero to one major risk
of patients is less than 160 mg/dL. physical activity, smoking cessation, and factor, drug treatment should be consid-
weight loss. Dietary changes should ered if the LDL-C cholesterol level is
Current treatment trends include a reduction of saturated fats to greater than or equal to 190 mg/dL after
With the increased emphasis on risk less than 7% of total calories, reduction of 3 months of TLC, with a goal of greater
assessment and aggressive new treatment intake of dietary cholesterol to less than than or equal to 160 mg/dL. In all cases
goals, it is estimated that the number of 200 mg/d, addition of plant sterols and of drug therapy, TLC should continue
patients eligible for CHD risk reduction stanols at a level of 2 g/d (commercially to be maintained and reinforced.
through lipid-modification therapy in the available in special margarines), and
United States is currently at 65 million. incorporating viscous fiber into the diet at Currently available
The type and extent of therapy is depen- a level of 10 g/d to 25 g/d. Weight reduc- lipid-modifying drugs
dent on the patient’s CHD risk. Two pri- tion can reduce LDL-C levels and ame- Four classes of lipid-modifying drugs
mary modalities advocated by ATP III liorate the risk factors associated with the are currently available in prescription
for lowering LDL-C, and therefore CHD metabolic syndrome by improving form, including bile acid sequestrants,
risk, are ATP TLC and drug therapy. insulin sensitivity and serum glucose nicotinic acids, fibric acid derivatives,
Clearfield • The National Cholesterol Education Program Adult Treatment Panel III guidelines JAOA • Supplement 1 • Vol 103 • No 1 • January 2003 • S3
S4 • JAOA • Supplement 1 • Vol 103 • No 1 • January 2003 Clearfield • The National Cholesterol Education Program Adult Treatment Panel III guidelines
Dr Clearfield is a professor of medicine and associate dean for clinical research at the University of North
Texas Health Science Center at Fort Worth/Texas College of Osteopathic Medicine. Dr Clearfield rep-
resented the American Osteopatic Association, a member organization of the National Cholesterol Edu-
cation Program Coordinating Committee, which approved the Third Report of the National Cholesterol
Education Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.
Dr Clearfield is a member of the speakers bureau of AstraZeneca, Merck & Co, Pfizer Inc, and
Sankyo Pharma Inc, and he has received grant/research support from AstraZeneca and Pfizer Inc.
Correspondence to Michael B. Clearfield, DO, Associate Dean for Clinical Research, Office of the Dean,
Texas College of Osteopathic Medicine, University of North Texas Health Science Center at Fort Worth,
855 Montgomery St, Fort Worth, TX 76107-2699.
E-mail: mclearfi@hsc.unt.edu
Clearfield • Underidentification and undertreatment of dyslipidemia JAOA • Supplement 1 • Vol 103 • No 1 • January 2003 • S5