New Standards for Lowering Cholesterol in Diabetic, Female, and Elderly Patients: a Clinician’s Point of View

With the release of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) guidelines, future risk of cardiac event supplanted the cholesterol number as the driving force behind intervention. These new prevention guidelines, based on recent subanalyses from major lipid-lowering clinical trials, support the concept of more aggressive cholesterol-lowering therapy for 3 groups who are currently undertreated: female, elderly, and diabetic patients. Results from the Heart Protection Study support the concept that cardiac risk can be significantly reduced with aggressive lipid-lowering therapy in these 3 groups. While the target levels of low-density lipoprotein, high-density lipoprotein, and triglyceride now advised by the NCEP are attainable, clinicians should be aware that monotherapy with statins may be inadequate for achieving the full set of lipid goals. Many patients may require combination regimens involving statins, bile acid sequestrants, niacin, or fibrates. (Advanced Studies in Medicine 2002;2(18):641-646) T he clinical guidelines published in 2001 by the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) do more than narrowly define the cholesterol target numbers for cardiovascular disease (CVD). They also shift the emphasis from lipid numbers alone to the overall risk of a future cardiac event in individual patients. The array of aggregate risk is now calculated using a new formula based on multiple risk factors (Table 1). Of special importance, the new standards encourage practitioners to look beyond the “typical” high-risk patient with CVD, represented by the middle-aged white male, to other high-risk groups who may also benefit from aggressive therapy, including female patients, diabetic patients, and elderly patients. This article reviews the rationale behind the new risk-driven NCEP recommendations and comments on the practical challenges in meeting these evolving standards.