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NCEP Cholesterol Guidelines Revisited

On the heels of several recent trials, LDL targets for some patients are being reconsidered.

Sponsoring Organizations: Coordinating Committee of the National Cholesterol Education Program (endorsed by the National Heart, Lung, and Blood Institute; the American College of Cardiology; and the American Heart Association)

Background and Purpose: Since the NCEP Adult Treatment Panel III guidelines were published (Journal Watch Cardiology Jun 15 2001), outcomes after use of cholesterol-lowering drugs have been studied in several major trials. This new report provides revised recommendations based on the new data. The proposed modifications reflect a more aggressive approach to cholesterol management, particularly in diabetes patients and other high-risk patients. (Some of the authors of this report have served as investigators on research funded by makers of statins.)

Key Points:

1. The recommended LDL-cholesterol target remains <100 mg/dL for most high-risk patients -- i.e., those with coronary heart disease or a CHD risk equivalent (10-year CHD risk >20%).

2. A new, optional target of <70 mg/dL has been recommended for patients deemed to be at "very high" risk -- i.e., patients with CHD who also have multiple or poorly controlled risk factors, including diabetes or the metabolic syndrome, and patients with a recent acute coronary syndrome event.

3. Pharmacologic therapy is now recommended for high-risk and very high-risk patients whose LDL levels are 100 mg/dL, along with requisite lifestyle changes.

4. For moderate-risk individuals -- those with two or more CHD risk factors (10-year CHD risk of 10%-20%) -- the LDL target remains <130 mg/dL. However, a target of <100 mg/dL is listed as a therapeutic option. Pharmacologic therapy is recommended for all eligible moderate-risk patients with an LDL level 130 mg/dL.

5. The new report continues to emphasize the importance of controlled cholesterol levels in patients aged 65 to 80. For those older than 80, evidence is scant and physician discretion is advised.

6. The new report discusses the importance of raising HDL levels without recommending specific targets. The emphasis remains on lowering LDL.

Comment: On the basis of findings from the PROSPER, ALLHAT-LLT, HPS, ASCOT-LLA, and PROVE-IT trials, the NCEP committee has taken a more aggressive stance on LDL-lowering, especially in high-risk and very high-risk individuals. For the first time, an optional LDL target of <70 mg/dL is advocated for certain high-risk patients. Although these guidelines support the role of lifestyle intervention, they emphasize that for the majority of patients, particularly high-risk and moderately high-risk patients, dietary interventions alone are inadequate to achieve recommended LDL reductions.

— JoAnne M. Foody, MD

Published in Journal Watch Cardiology September 3, 2004

Citation(s):

Grundy SM et al. for the Coordinating Committee of the National Cholesterol Education Program. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004 Jul 13; 110:227-39.

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