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Updated Cholesterol Guidelines: Consider Lower LDL Targets in Patients at High Risk

LDL-cholesterol goals still are 130-160 mg/dL for low- or intermediate-risk patients, but high-risk patients might warrant very aggressive cholesterol-lowering therapy, with targets as low as 70 mg/dL.

The National Cholesterol Education Panel (NCEP) Adult Treatment Panel III published its recommendations in 2001. Since then, results from several large clinical trials on lipid management have been published. The NCEP Coordinating Committee (most of the members of the working group report some financial ties to the pharmaceutical industry) now has reviewed these studies and has issued a report on their implications for clinical practice. Salient features include these points:

• Therapeutic lifestyle changes (TLC) remain a cornerstone of lipid management. Moreover, people at high risk (i.e., established coronary heart disease, CHD equivalents, or multiple risk factors and 10-year risk >20%) or moderately high risk (two or more risk factors and 10-year risk of 10%-20%) are candidates for TLC, regardless of LDL-cholesterol levels.
  
• For high-risk patients, the recommended LDL-cholesterol goal remains <100 mg/dL; however, especially in very-high-risk patients, an LDL-cholesterol goal of <70 mg/dL is a therapeutic option. Concurrent TLC and LDL-cholesterol-lowering drug therapy are indicated if baseline LDL-cholesterol levels are 100 mg/dL. LDL-cholesterol-lowering drugs are a therapeutic option to achieve LDL-cholesterol levels <70 mg/dL, even if baseline LDL-cholesterol levels are <100 mg/dL.
  
• For high-risk patients with high triglyceride or low HDL-cholesterol levels, combination therapy with an LDL-cholesterol-lowering drug and either fibrates or nicotinic acid should be considered. When triglycerides are high (200 mg/dL), non-HDL-cholesterol (i.e., total cholesterol minus HDL-cholesterol) is a secondary target for therapy, with a goal 30 mg/dL higher than the corresponding LDL-cholesterol goal.
  
• For moderately high- or high-risk patients, LDL-cholesterol-lowering drug therapy should achieve at least a 30%-40% reduction in LDL-cholesterol levels.
  
• For patients at lower risk, recent trial results do not support modification of previous LDL-cholesterol goals and targets (130 mg/dL for moderate-risk patients and 160 mg/dL for low-risk patients).
  

Comment: In this new update, the panel takes into account several recent trials that confirm the benefit of LDL-cholesterol-lowering drug therapy in patients at high risk, including patients with diabetes. Some of these results also suggest that lower LDL-cholesterol targets than those recommended in the original NCEP III guidelines would be appropriate for patients with high or very-high risk. The new guidelines expand the number of patients who are eligible for LDL-cholesterol-lowering drug therapy; however, the importance of therapeutic lifestyle changes and of treatment for metabolic syndrome cannot be overemphasized.

— Kirsten E. Fleischmann, MD, MPH

Published in Journal Watch General Medicine September 7, 2004

Citation(s):

Grundy SM et al. 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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