Since the full report of the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) was published in 2002, new clinical evidence has suggested that--at least in high-risk and moderate-risk patients--reducing LDL cholesterol to very low levels (i.e., to below 70 mg/dL instead of the currently recommended 100 -130 mg/dL) significantly reduces the risk of death and cardiovascular events.
In response, the NCEP commented on this new information, publishing an update on the ATP III guidelines in 2004. In general, the ATP III guidelines now recommend that LDL cholesterol levels be brought below 100 mg/dL in high-risk and moderate risk patients. This compares to target levels below 130 mg/dL in the past.
Specifically, the new recommendations are:
For high-risk patients (those with a 10-year risk* of a cardiac event > 20%): The LDL cholesterol should be lowered to < 100 mg/dL, and consideration should be given to lowering it to < 70 mg/dL.
For moderately high-risk patients (those with a 10-year risk* of a cardiac event between 10 and 20%): LDL cholesterol should be lowered to < 130 mg/dL, and consideration should be given to lowering it to < 100 mg/dL.
For moderate-risk patients (those with a 10-year risk* of a cardiac event < 10%): LDL cholesterol should be lowered to < 130 mg/dL.
For low-risk patients (those with a 10-year risk* of a cardiac event < 1%): LDL cholesterol should be lowered to < 160 mg/dL.
Most observers in the field have come out in strong support of these new recommendations, though there are some critics. On one hand, some critics argue that even the new recommendations are not strong enough in light of recent clinical trials, and that a target of 70 mg/dL or lower should be emphasized much more strongly. On the other hand, others (those fond of slamming the pharmaceutical industry) point out that many members of the NCDP ATP III panel have ties to the companies that make statin drugs, and that their recommendations are biased.
Dr. Rich comments:
To me, the evidence that reducing LDL cholesterol in high-risk patients to very low levels is significantly beneficial is now compelling, and the 2004 revision to the ATP III guidelines are, if anything, conservative. The NCEP panel, to its credit, has now demonstrated the ability and willingness to act quickly when compelling data becomes available.
By the way, most substantial advances in medicine occur in the U.S. through the efforts and funding of the pharmaceutical industry. (While some may not like that, compare the advances in medicine that arise in the U.S. to advances that arise in countries where medical industry is price-controlled.) In any case, under our system, the clinicians who conduct clinical trials will almost necessarily have associations with industry. While it is fair to point out these associations and to take them into account, it is not productive to use those associations alone to denigrate the recommendations made by experts in a particular field. In Dr. Rich's opinion, the scientific evidence in this particular case completely overwhelms such issues of potential bias.
* You can find out how to assess your own 10-year risk of heart disease here.
Sources:
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.
