Changing lipid-lowering guidelines: Whom to treat and how low to go

Abstract

Results of recent lipid-lowering statin trials, including the Heart Protection Study (HPS), Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT), Arterial Biology for the Investigation of the Treatment Effects of Reducing Cholesterol (ARBITER), Reversal of Atherosclerosis with Aggressive Lipid Lowering (REVERSAL), and Pravastatin or Atorvastatin Evaluation and Infection Therapy (PROVE IT), have provided compelling evidence that both low-density lipoprotein cholesterol (LDL-C) cut-points for initiation of lipid-lowering treatment and LDL-C treatment goals in patients at high or moderately high risk of coronary heart disease have been set too high. This evidence has resulted in recent revisions to the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines, including recommendations for initiation of therapy in high risk patients with LDL-C ≥ 100 mg/dL (2.6 mmol/L); optional initiation of therapy in very high risk patients with LDL-C < 100 mg/dL, with an optional target of LDL-C < 70 mg/dL (1.8 mmol/L); and optional initiation of therapy in moderately high risk patients with LDL-C of 100-129 mg/dL (2.6-3.3 mmol/L), with an optional target of < 100 mg/dL. It is also recommended that lipid-lowering therapy in patients with high or moderately high risk be initiated at an intensity sufficient to produce a 30-40% reduction in LDL-C. Results of ongoing statin trials examining the effects of treatment to low LDL-C targets on clinical events will soon be available, and these will help to further refine optimal therapeutic goals. © The European Society of Cardiology 2005. All rights reserved.