A Summary of Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines
2004; Lippincott Williams & Wilkins; Volume: 24; Issue: 8 Linguagem: Inglês
10.1161/01.atv.0000139012.45265.e0
ISSN1524-4636
AutoresScott M. Grundy, James I. Cleeman, C. Noel Bairey Merz, H. Bryan Brewer, Luther T. Clark, Donald B. Hunninghake, Richard C. Pasternak, Sidney C. Smith, Neil J. Stone,
Tópico(s)Lipoproteins and Cardiovascular Health
ResumoHomeArteriosclerosis, Thrombosis, and Vascular BiologyVol. 24, No. 8A Summary of Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBA Summary of Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines Scott M. Grundy, James I. Cleeman, C. Noel Bairey Merz, H. Bryan BrewerJr, Luther T. Clark, Donald B. Hunninghake, Richard C. Pasternak, Sidney C. SmithJr, Neil J. Stone and Scott M. GrundyScott M. Grundy , James I. CleemanJames I. Cleeman , C. Noel Bairey MerzC. Noel Bairey Merz , H. Bryan BrewerJrH. Bryan BrewerJr , Luther T. ClarkLuther T. Clark , Donald B. HunninghakeDonald B. Hunninghake , Richard C. PasternakRichard C. Pasternak , Sidney C. SmithJrSidney C. SmithJr , Neil J. StoneNeil J. Stone and and for the Coordinating Committee of the National Cholesterol Education Program Originally published1 Aug 2004https://doi.org/10.1161/01.ATV.0000139012.45265.e0Arteriosclerosis, Thrombosis, and Vascular Biology. 2004;24:1329–1330The Adult Treatment Panel III (ATP III) of the National Cholesterol Education Program (NCEP) issued an evidence-based set of guidelines on cholesterol management in 2001. Since the publication of ATP III, five major clinical trials of statin therapy with clinical end points have been published. These trials addressed issues that were not examined in previous clinical trials of cholesterol-lowering therapy. An NCEP working group reviewed the results of these recent trials and assessed their implications for cholesterol management. These clinical trials strongly support the ATP III recommendation that LDL-cholesterol (LDL-C) should be the primary target of lipid-lowering therapy. The trials confirm the benefit of cholesterol-lowering therapy in high-risk patients and support the ATP III treatment goal of LDL-C <100 mg/dL. In fact, they add to the growing evidence supporting the concept that, for LDL-C in high-risk patients, "the lower, the better" for reducing risk for major cardiovascular events (Figure). Although recent clinical trials focused on drug therapies for LDL lowering, the NCEP update affirms that therapeutic lifestyle changes (TLC) remain an essential modality in clinical management. TLC has the potential to reduce cardiovascular risk through several mechanisms beyond LDL lowering. Recent clinical trials support the inclusion of patients with diabetes in the high-risk category and confirm the benefits of LDL-lowering therapy in these patients. They further confirm that older persons benefit from therapeutic lowering of LDL-C. The major recommendations for modifications to footnote the ATP III treatment algorithm for LDL lowering are presented in the Table 1 and are summarized in Table 2. In high-risk persons, ATP III established that the recommended LDL-C goal is <100 mg/dL; when triglycerides are high (≥200 mg/dL), a secondary goal is a non–HDL-C <130 mg/dL. According to the update, when risk is very high, an LDL-C goal of <70 mg/dL is a therapeutic option, ie, a reasonable clinical strategy, based on available clinical trial evidence. This therapeutic option extends also to patients at very high risk who have a baseline LDL-C <100 mg/dL. For those very high risk patients who have a high triglyceride, a level of non–HDL-C of <100 mg/dL corresponds to an LDL-C level of <70 mg/dL. Identifying a very high risk patient depends on clinical judgment. Examples of such patients include those with established cardiovascular disease plus (1) multiple major risk factors (especially diabetes), (2) severe and poorly controlled risk factors (especially continued cigarette smoking), (3) multiple risk factors of the metabolic syndrome (especially high triglyceride ≥200 mg/dL plus non–HDL-C ≥130 mg/dL with low HDL-C [ 50% obstruction of a carotid artery]), diabetes, and 2+ risk factors with 10-year risk for hard CHD >20%.‡Risk factors include cigarette smoking, hypertension (BP ≥140/90 mm Hg or on antihypertensive medication), low HDL cholesterol (<40 mg/dL), family history of premature CHD (CHD in male first degree relative <55 years; CHD in female first degree relative <65 years), and age (men ≥45 years; women ≥55 years)§Almost all people with 0–1 risk factor have a 10-year risk <10%, and 10-year risk assessment in people with 0–1 risk factor is thus not necessary.¶Very high risk favors the optional LDL-C goal of <70 mg/dL∥Optional LDL-C goal <100 mg/dL.**Any person at high-risk or moderately high risk who has lifestyle-related risk factors (eg, obesity, physical inactivity, elevated triglyceride, low HDL-C, or metabolic syndrome) is a candidate for therapeutic lifestyle changes to modify these risk factors regardless of LDL-C level.††When LDL-lowering drug therapy is used, it is advised that intensity of therapy be sufficient to achieve at least a 30%–40% reduction in LDL-C levels.‡‡If baseline LDL-C is <100 mg/dL, institution of an LDL-lowering drug is a therapeutic option based on available clinical trial results. If a high-risk person has high triglycerides or low HDL-C, combining a fibrate or nicotinic acid with an LDL-lowering drug can be considered.§§For moderately high-risk persons, when LDL-C level is 100–129 mg/dL, at baseline or on lifestyle therapy, initiation of an LDL-lowering drug to achieve an LDL-C level 20%) High Risk<100 mg/dL (optional goal: <70 mg/dL)¶≥100 mg/dL**≥100 mg/dL‡‡ (<100 mg/dL: consider drug options)††2+ Risk Factors‡ (10-year risk 10%–20%) Moderately High Risk<130 mg/dL∥≥130 mg/dL**≥130 mg/dL (100–129 mg/dL; consider drug options)§§2+ Risk Factors‡ (10-year risk <10%) Moderate Risk<130 mg/dL≥130 mg/dL≥160 mg/dL0–1 Risk Factor§<160 mg/dL≥160 mg/dL≥190 mg/dL (160–189 mg/dL: LDL-lowering drug optional)TABLE 2. Recommendations for Modifications to Footnote the ATP III Treatment Algorithm for LDL-Cholesterol (LDL-C)Therapeutic lifestyle changes (TLC) remain an essential modality in clinical management. TLC has the potential to reduce cardiovascular risk through several mechanisms beyond LDL lowering.In high-risk persons, the recommended LDL-C goal is <100 mg/dL. An LDL-C goal of <70 mg/dL is a therapeutic option based on available clinical trial evidence, especially for patients at very high risk. If LDL-C is ≥100 mg/dL, an LDL-lowering drug is indicated simultaneously with lifestyle changes. If baseline LDL-C is <100 mg/dL, institution of an LDL-lowering drug to achieve an LDL-C level <70 mg/dL is a therapeutic option based on available clinical trial evidence. If a high-risk person has high triglycerides or low HDL-C, consideration can be given to combining a fibrate or nicotinic acid with an LDL-lowering drug. When triglycerides are ≥200 mg/dL, non–HDL-C is a secondary target of therapy, with a goal 30 mg/dL higher than the identified LDL-C goalFor moderately high-risk persons (2+ risk factors and 10-year risk 10%–20%), the recommended LDL-C goal is <130 mg/dL; an LDL-C goal <100 mg/dL is a therapeutic option based on available clinical trial evidence. When LDL-C level is 100–129 mg/dL, at baseline or on lifestyle therapy, initiation of an LDL-lowering drug to achieve an LDL-C level <100 mg/dL is a therapeutic option based on available clinical trial evidence.Any person at high-risk or moderately high risk who has lifestyle-related risk factors (eg, obesity, physical inactivity, elevated triglyceride, low HDL-C, or metabolic syndrome) is a candidate for therapeutic lifestyle changes to modify these risk factors regardless of LDL-C level.When LDL-lowering drug therapy is used in high-risk or moderately high-risk persons, it is advised that intensity of therapy be sufficient to achieve at least a 30%–40% reduction in LDL-C levels.For people in lower-risk categories, recent clinical trials do not modify the goals and cut points of therapy.See page e149For moderately high-risk persons (2+ risk factors and 10-year risk 10% to 20%), the recommended LDL-C goal is <130 mg/dL; but an LDL-C goal <100 mg/dL is a therapeutic option based on recent trial evidence. The latter option extends also to moderately high risk persons with a baseline LDL-C of 100 to 129 mg/dL. When LDL-lowering drug therapy is used in high-risk or moderately high-risk persons, it is advised that intensity of therapy be sufficient to achieve at least a 30% to 40% reduction in LDL-C levels. Moreover, any person at high risk or moderately high risk who has lifestyle-related risk factors (eg, obesity, physical inactivity, elevated triglyceride, low HDL-C, or metabolic syndrome) is a candidate for TLC to modify these risk factors regardless of LDL-C level.Finally, for people in lower-risk categories, recent clinical trials do not modify the goals and cut points of therapy.The financial disclosure of the writing group panel of the ATP III update can be viewed on the National Heart, Lung, and Blood Institute website at http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3upd04.htm*D.B.H. was a member of the Working Group until December 31, 2003.FootnotesCorrespondence to Scott Grundy, University of Texas Southwestern Medical Center, Center for Human Nutrition, Dallas, TX 75390-9052. Previous Back to top Next FiguresReferencesRelatedDetailsCited By Mauss D and Jarczok M (2021) The streamlined allostatic load index is associated with perceived stress in life – findings from the MIDUS study, Stress, 10.1080/10253890.2020.1869935, 24:4, (404-412), Online publication date: 4-Jul-2021. Wang H, Lee D, Liu M, Portincasa P and Wang D (2020) Novel Insights into the Pathogenesis and Management of the Metabolic Syndrome, Pediatric Gastroenterology, Hepatology & Nutrition, 10.5223/pghn.2020.23.3.189, 23:3, (189), . Parmar G, Novak Z, Spangler E, Patterson M, Passman M, Beck A and Pearce B (2019) Statin use improves limb salvage after intervention for peripheral arterial disease, Journal of Vascular Surgery, 10.1016/j.jvs.2018.07.089, 70:2, (539-546), Online publication date: 1-Aug-2019. Pollin T, Ordovas J and Guevara-Cruz M (2017) Genetic Influences on Blood Lipids and Cardiovascular Disease Risk Nutrition in the Prevention and Treatment of Disease, 10.1016/B978-0-12-802928-2.00026-6, (571-593), . Kodaman N, Aldrich M, Sobota R, Asselbergs F, Brown N, Moore J and Williams S (2016) Plasminogen Activator Inhibitor‐1 and Diagnosis of the Metabolic Syndrome in a West African Population, Journal of the American Heart Association, 5:10, Online publication date: 3-Oct-2016. Piepoli M, Hoes A, Agewall S, Albus C, Brotons C, Catapano A, Cooney M, Corrà U, Cosyns B, Deaton C, Graham I, Hall M, Hobbs F, Løchen M, Löllgen H, Marques-Vidal P, Perk J, Prescott E, Redon J, Richter D, Sattar N, Smulders Y, Tiberi M, van der Worp H, van Dis I, Verschuren W, De Backer G, Roffi M, Aboyans V, Bachl N, Bueno H, Carerj S, Cho L, Cox J, De Sutter J, Egidi G, Fisher M, Fitzsimons D, Franco O, Guenoun M, Jennings C, Jug B, Kirchhof P, Kotseva K, Lip G, Mach F, Mancia G, Bermudo F, Mezzani A, Niessner A, Ponikowski P, Rauch B, Rydén L, Stauder A, Turc G, Wiklund O, Windecker S and Zamorano J (2016) 2016 European Guidelines on cardiovascular disease prevention in clinical practice, European Journal of Preventive Cardiology, 10.1177/2047487316653709, 23:11, (NP1-NP96), Online publication date: 1-Jul-2016. Berezin A, Kremzer A, Berezina T, Martovitskaya Y and Gromenko E (2016) Relation of osteoprotegerin level and numerous of circulating progenitor mononuclears in patients with metabolic syndrome, Biomedical Research and Therapy, 10.7603/s40730-016-0007-7, 3:2, Online publication date: 1-Mar-2016. Mahmood D, Jahan K and Habibullah K (2015) Primary prevention with statins in cardiovascular diseases: A Saudi Arabian perspective, Journal of the Saudi Heart Association, 10.1016/j.jsha.2014.09.004, 27:3, (179-191), Online publication date: 1-Jul-2015. Mauss D, Jarczok M and Fischer J (2015) A streamlined approach for assessing the Allostatic Load Index in industrial employees, Stress, 10.3109/10253890.2015.1040987, 18:4, (475-483), Online publication date: 4-Jul-2015. Kones R and Rumana U (2015) Current Treatment of Dyslipidemia: A New Paradigm for Statin Drug Use and the Need for Additional Therapies, Drugs, 10.1007/s40265-015-0428-4, 75:11, (1187-1199), Online publication date: 1-Jul-2015. Fernández-Laso V, Sastre C, Egido J, Martín-Ventura J and Blanco-Colio L (2015) La atorvastatina inhibe la progresión de la lesión aterosclerótica inducida por el factor inductor débil de apoptosis similar al factor de necrosis tumoral en ratones deficientes en apolipoproteína E, Clínica e Investigación en Arteriosclerosis, 10.1016/j.arteri.2014.04.003, 27:1, (17-25), Online publication date: 1-Jan-2015. Jose M. O and Martha G (2013) Genetic Influences on Blood Lipids and Cardiovascular Disease Risk Nutrition in the Prevention and Treatment of Disease, 10.1016/B978-0-12-391884-0.00028-7, (519-540), . Parmar G, Lowman B, Combs B, Taylor S, Patterson M, Passman M and Jordan W (2013) Effect of lipid-modifying drug therapy on survival after abdominal aortic aneurysm repair, Journal of Vascular Surgery, 10.1016/j.jvs.2013.01.036, 58:2, (355-363), Online publication date: 1-Aug-2013. Chang Y, Guo C, Tsai M, Cheng Y, Lin M, Chen C, Shen D, Wang J and Sung J (2012) Poor immune response to a standard single dose non-adjuvanted vaccination against 2009 pandemic H1N1 influenza virus A in the adult and elder hemodialysis patients, Vaccine, 10.1016/j.vaccine.2012.05.016, 30:33, (5009-5018), Online publication date: 1-Jul-2012. Han J, Kim J and Kim A (2012) The Effects of Auricularia auricula-judae on Blood Lipids Profile and Bone Density of Middle Aged Abdominal Obese Women, The Korean Journal of Food And Nutrition, 10.9799/ksfan.2012.25.4.1075, 25:4, (1075-1080), Online publication date: 31-Dec-2013. Wang M, Liu J, Ma C, Wang W, Liu X, Li Y, Sun J, Liu J, Qi Y, Lv Q and Zhao D (2012) Synergistic Association of Serum Albumin and Globulin with Coronary Heart Disease, Journal of Atherosclerosis and Thrombosis, 10.5551/jat.10322, 19:7, (619-632), . Tvarijonaviciute A, Ceron J, Holden S, Cuthbertson D, Biourge V, Morris P and German A (2012) Obesity-related metabolic dysfunction in dogs: a comparison with human metabolic syndrome, BMC Veterinary Research, 10.1186/1746-6148-8-147, 8:1, Online publication date: 1-Dec-2012. Bhattacharjee S, Findley P and Sambamoorthi U (2012) Understanding Gender Differences in Statin Use among Elderly Medicare Beneficiaries, Drugs & Aging, 10.1007/s40266-012-0032-1, 29:12, (971-980), Online publication date: 1-Dec-2012. Takahashi S, Ito T, Zenimaru Y, Suzuki J, Miyamori I, Takahashi M, Takahashi M, Ishida T, Ishida T, Hirata K, Yamamoto T, Iwasaki T, Hattori H and Shiomi M (2011) Species differences of macrophage very low-density-lipoprotein (VLDL) receptor protein expression, Biochemical and Biophysical Research Communications, 10.1016/j.bbrc.2011.03.069, 407:4, (656-662), Online publication date: 1-Apr-2011. Berthold H, Krone W, Erdmann E and Gouni-Berthold I (2011) Lipid lowering in patients with chronic kidney disease: a SHARP turn in the wrong direction?, European Journal of Cardiovascular Prevention & Rehabilitation, 10.1177/1741826711423116, 18:6, (858-861), Online publication date: 1-Dec-2011. Bilotti E, Gleason C and McNeill A (2011) Routine Health Maintenance in Patients Living With Multiple Myeloma, Clinical Journal of Oncology Nursing, 10.1188/11.S1.CJON.25-40, 15:0, (25-40), Online publication date: 1-Aug-2011. Puato M, Faggin E, Rattazzi M, Zambon A, Cipollone F, Grego F, Ganassin L, Plebani M, Mezzetti A and Pauletto P (2010) Atorvastatin Reduces Macrophage Accumulation in Atherosclerotic Plaques, Stroke, 41:6, (1163-1168), Online publication date: 1-Jun-2010. Feig J, Pineda-Torra I, Sanson M, Bradley M, Vengrenyuk Y, Bogunovic D, Gautier E, Rubinstein D, Hong C, Liu J, Wu C, van Rooijen N, Bhardwaj N, Garabedian M, Tontonoz P and Fisher E (2010) LXR promotes the maximal egress of monocyte-derived cells from mouse aortic plaques during atherosclerosis regression, Journal of Clinical Investigation, 10.1172/JCI38911, 120:12, (4415-4424), Online publication date: 1-Dec-2010. Newman A, Bayles C, Milas C, McTigue K, Williams K, Robare J, Taylor C, Albert S and Kuller L (2010) The 10 Keys to Healthy Aging: Findings From an Innovative Prevention Program in the Community, Journal of Aging and Health, 10.1177/0898264310363772, 22:5, (547-566), Online publication date: 1-Aug-2010. Hoogwerf B (2010) Diabetes Mellitus Current Clinical Medicine, 10.1016/B978-1-4160-6643-9.00051-5, (350-354.e2), . Ordovas J (2009) Genetic influences on blood lipids and cardiovascular disease risk: tools for primary prevention, The American Journal of Clinical Nutrition, 10.3945/ajcn.2009.27113E, 89:5, (1509S-1517S), Online publication date: 1-May-2009. Schwellnus M, Patel D, Nossel C, Dreyer M, Whitesman S and Derman E (2014) Healthy lifestyle interventions in general practice Part 6: Lifestyle and metabolic syndrome, South African Family Practice, 10.1080/20786204.2009.10873841, 51:3, (177-181), Online publication date: 1-May-2009. Stephenson S, Larrinaga-Shum S and Hopkins P (2009) Benefits of the MEDPED treatment support program for patients with familial hypercholesterolemia, Journal of Clinical Lipidology, 10.1016/j.jacl.2009.02.004, 3:2, (94-100), Online publication date: 1-Apr-2009. Torres do Rego A, Álvarez-Sala Walter L and Conthe Gutiérrez P (2008) Lípidos y enfermedad cerebrovascular. El papel de las estatinas. Nuevas opciones hipolipemiantes en investigación, Revista Clínica Española, 10.1016/S0014-2565(08)71784-3, 208, (13-18), Online publication date: 1-Sep-2008. Brinton E (2008) Does the addition of fibrates to statin therapy have a favorable risk to benefit ratio?, Current Atherosclerosis Reports, 10.1007/s11883-008-0005-3, 10:1, (25-32), Online publication date: 1-Jan-2008. Sikorski J (2007) Atherosclerosis/Lipoprotein/Cholesterol Metabolism Comprehensive Medicinal Chemistry II, 10.1016/B0-08-045044-X/00180-2, (459-494), . Suárez C, Cairols M, Castillo J, Esmatjes E, Sala J, Llobet X and Carlos Palma J (2007) Control de factores de riesgo y tratamiento de la aterotrombosis. Registro REACH España, Medicina Clínica, 10.1016/S0025-7753(07)72882-8, 129:12, (446-450), Online publication date: 1-Oct-2007. Kojić-Damjanov S, đerić M, Čabarkapa V and Vučurević-Ristić L Significance of Determining Levels of Apolipoproteins A-I and B in the Diagnostics and Assessment of Lipid-Related Atherogenic Risk in Hyperalpha-Lipoproteinemia, Hypocholesterolemia and Hypo-Hdl-Cholesterolemia, Journal of Medical Biochemistry, 10.2478/v10011-007-0024-6, 26:3, (206-214) Botella Carretero J, Fresneda Moreno J and Manzano Espinosa L (2006) Papel de los antagonistas de los receptores de la angiotensina II en el tratamiento del síndrome metabólico, Revista Clínica Española, 10.1157/13088590, 206:6, (284-288), Online publication date: 1-Jun-2006. Ojo A (2006) Cardiovascular Complications After Renal Transplantation and Their Prevention, Transplantation, 10.1097/01.tp.0000235527.81917.fe, 82:5, (603-611), Online publication date: 1-Sep-2006. Levinson S (2005) Brief review and critical examination of the use of hs-CRP for cardiac risk assessment with the conclusion that it is premature to use this test, Clinica Chimica Acta, 10.1016/j.cccn.2004.12.021, 356:1-2, (1-8), Online publication date: 1-Jun-2005. Mattoo V, Eckland D, Widel M, Duran S, Fajardo C, Strand J, Knight D, Grossman L, Oakley D and Tan M (2005) Metabolic effects of pioglitazone in combination with insulin in patients with type 2 diabetes mellitus whose disease is not adequately controlled with insulin therapy: Results of a six-month, randomized, double-blind, prospective, multicenter, parallel-group study, Clinical Therapeutics, 10.1016/j.clinthera.2005.05.005, 27:5, (554-567), Online publication date: 1-May-2005. Goldberg R, Kendall D, Deeg M, Buse J, Zagar A, Pinaire J, Tan M, Khan M, Perez A and Jacober S (2005) A Comparison of Lipid and Glycemic Effects of Pioglitazone and Rosiglitazone in Patients With Type 2 Diabetes and Dyslipidemia, Diabetes Care, 10.2337/diacare.28.7.1547, 28:7, (1547-1554), Online publication date: 1-Jul-2005. Olyaei A, deMattos A and Bennett W (2005) Cardiovascular complications of immunosuppressive agents in renal transplant recipients, Expert Opinion on Drug Safety, 10.1517/14740338.4.1.29, 4:1, (29-44), Online publication date: 1-Jan-2005. Hellinger J, Cohen C, Morris A, Sheble-Hall S, Gordon D, Foy C, Jackson-Pope L, Shevitz A and van Schaic E (2015) Pilot Study of Saquinavir and Lopinavir/Ritonavir Twice Daily in Protease Inhibitor-Naive HIV-Positive Patients, HIV Clinical Trials, 10.1310/YGKE-7K4V-UF5R-4F1G, 6:2, (107-117), Online publication date: 1-Apr-2005. Feig J, Vengrenyuk Y, Reiser V, Wu C, Statnikov A, Aliferis C, Garabedian M, Fisher E, Puig O and Colombo G (2012) Regression of Atherosclerosis Is Characterized by Broad Changes in the Plaque Macrophage Transcriptome, PLoS ONE, 10.1371/journal.pone.0039790, 7:6, (e39790) Feig J, Shang Y, Rotllan N, Vengrenyuk Y, Wu C, Shamir R, Torra I, Fernandez-Hernando C, Fisher E, Garabedian M and Niess J (2011) Statins Promote the Regression of Atherosclerosis via Activation of the CCR7-Dependent Emigration Pathway in Macrophages, PLoS ONE, 10.1371/journal.pone.0028534, 6:12, (e28534) Sun Y, Ren J, Zhu S, Zhang Z, Guo Z, An J, Yin B and Ma Y (2022) The Effects of Sesamin Supplementation on Obesity, Blood Pressure, and Lipid Profile: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, Frontiers in Endocrinology, 10.3389/fendo.2022.842152, 13 August 2004Vol 24, Issue 8 Advertisement Article InformationMetrics https://doi.org/10.1161/01.ATV.0000139012.45265.e0PMID: 15297284 Originally publishedAugust 1, 2004 PDF download Advertisement
Referência(s)