The first step in following ATP III recommendations is to decide whether you need to be treated at all. This is done by measuring your LDL cholesterol level, and by assessing your risk of developing heart disease over the next 10 years. During that risk-assessment process, you will be categorized as having low, intermediate, or high risk.
Cholesterol Treatment For Low-Risk Patients
If you are in the low-risk category, current recommendations set your target LDL level as less than 160 mg/dL. This means that if your LDL level is 160 or higher, your doctor will recommend lifestyle changes to reduce your cholesterol levels. Specifically, dietary changes, exercise, smoking cessation, and weight control can bring your LDL cholesterol down. If you are in the low-risk category and your LDL level is 190 or higher, your doctor may recommend drug treatment.Cholesterol Treatment For Intermediate-Risk Patients
If you are in the intermediate-risk category, ATP III guidelines set your target LDL level as 129 mg/dL or lower. If your measured LDL level is 130 or higher, the guidelines recommend lifestyle changes as a first step; and if your LDL levels are above 159, drug therapy should be strongly considered.Since the ATP III guidelines were published, a lot of new data has been published regarding the treatment of intermediate-risk patients that, many experts think, make the guidelines somewhat obsolete. So if you are in the intermediate-risk group, here are some things you and your doctor now ought to take into account when deciding on your therapy:
- Based on new evidence, many experts now think the target LDL level for intermediate-risk patients should be less than 100 mg/dl, instead of less than 130 mg/dL.
- Several studies strongly suggest that statin drugs can reduce the cardiac risk in intermediate-risk patients (whatever their baseline LDL cholesterol levels) by as much as 20 - 30%. So, for instance, if your 10-year risk is 15%, a statin can reduce it to about 10.5%. So you may want to discuss the pros and cons of statin therapy (i.e., risk reduction versus the drug expense and the possibility of side effects) with your doctor even if your LDL level is in the "lifestyle changes" range.
- Some experts recommend attempting to further characterize the risk of intermediate-risk patients as being either "relatively high risk" or "relatively low risk," and offering statins to those whose risk seems relatively high. Methods that have been used to further characterize risk include cardiac calcium scans, and measuring CRP levels. In particular, the JUPITER trial suggests that CRP levels may be important in selecting patients who will have better outcomes with statin therapy.
Cholesterol Treatment For High-Risk Patients
If you are in the high-risk category, ATP III guidelines set your target LDL level at less than 100 mg/dL. If your measured LDL level is 100 or greater, both lifestyle changes and drug treatment should be considered.Here again, more data has come to light since the ATP III guidelines were published. So if you are in the high-risk category, here are some things you and your doctor now ought to keep in mind when deciding on your cholesterol treatment:
- Most experts recommend classifying a subset of patients in the high-risk category as being at "very high risk." In particular, these are patients with known coronary artery disease plus several poorly-controlled cardiac risk factors (especially ongoing tobacco use), or acute coronary syndrome. Evidence suggests that these patients should be treated with intensive statin therapy sufficient to reduce their LDL cholesterol levels to below 70 mg/dL.
- Patients in the high-risk category (but not in the "very high risk" category) should probably receive statin therapy (as opposed to other drug treatment) at least sufficient to reduce their LDL cholesterol to below 100 mg/dL.
- Most experts now think that patients in the high-risk category should receive a statin immediately, without waiting to see if a trial of lifestyle modification alone can reduce cholesterol levels.
Why Statins?
You have probably noticed that when drug therapy for lowering cholesterol is suggested, the recommendation is always to use statins rather than any of the other kinds of drugs approved for cholesterol-lowering.This is because the evidence from clinical trials that statins can reduce major cardiac events and mortality in patients with elevated cardiac risk is much stronger than it is for any other kind of cholesterol-lowering medication. In fact, several clinical trials with non-statin drugs appear to have shown a trend toward worse outcomes, despite the fact that cholesterol levels were reduced.
So if you need drug therapy for cholesterol reduction, your doctor will almost certainly begin with a statin drug, and use one of the non-statin cholesterol agents only if you cannot tolerate statins.
Sources:
Third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Circulation 2002; 106:3143.
Grundy SM, Cleeman JI, Bairey Merz CN, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004;110:227-239.
Hayward, RA, Krumholz, HM, Zulman, DM, et al. Optimizing statin treatment for primary prevention of coronary artery disease. Ann Intern Med 2010; 152:69.
Rosenson, RS, Lloyd-Jones, D. A critical appraisal of revised cholesterol guidelines for the very high-risk patient. Expert Rev Cardiovasc Ther 2005; 3:173.
