The New Cholesterol Guidelines (Published May 21, 2001)

After eight years, the National Cholesterol Education Program operating under the aegis of the National Institutes of Health has released their third iteration of guidelines to the assessment and management of blood fat abnormalities. These are based on the best available and reliable evidence of benefit to the patient.

As a practicing preventive cardiologist, lecturer and a lipid researcher (starting at the NIH) since 1974, I have anticipated these recommendations for over a year. This is what I believe patients need to know about what these Adult Treatment Panel III recommendations really mean.

The absolute levels of bad cholesterol, LDL-cholesterol, that require treatment have not really changed, although the acceptable level of good cholesterol has been raised to 40 mg/dL. What has changed is who is eligible for treatment to those goal levels. The body of evidence clearly suggests that what was acceptable before is no longer reasonable. Clearly, the information we have now indicates that if one has cardiovascular disease, or has any significant risk factors, the lower the cholesterol level, the better. There are new categories of coronary disease “equivalents”, meaning that if you have these diseases, you should be treated as aggressively as if you have clinical coronary artery disease. These equivalent conditions include peripheral artery disease, carotid artery disease, type 2 diabetes, or are at a calculated risk of twenty percent or more of developing heart disease over the next decade.

These guidelines will make it imperative for doctors and patients to examine their cardiovascular risk factors, and will also make it more complicated for doctors to evaluate their patient's risk. The Framingham Risk Appraisal, alluded to in prior columns, was published in 1998 and forms a key part of the risk estimate. To help doctors and patients evaluate these factors, the NIH has provided help at their web site, . There are sections for doctors and patients, as well as a calculator for risk. I suggest that you browse the patient section, and address any concerns and questions about your own status to your doctor.

Much of the coverage of these new NCEP/ATP III guidelines has been focused on the cost of treating patients to these new recommended levels. Comments about tripling the number of eligible patients, raising the cost of statin drugs to $30 billion per year, and who will pay for all of this have been part of most stories. It is what it is. In order to care for patients optimally, we cannot ignore the enormous body of evidence that has been accumulated since the first guidelines were issued in 1987. The impetus for prescription drug benefits in Medicare and other insurance plans will likely increase.

Additionally, it is very important to know that just being on a cholesterol lowering drug is not the answer. Having the various blood fat levels at the recommended goal levels is the target for which one should strive. Medications should only be used if lifestyle changes have been not successful. But if medications are required, make sure that the goals of therapy are defined and that all reasonable efforts to achieve those levels have been made. The beneficiary of all of this is your cardiovascular health.


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