In July 2004, the NCEP published a paper entitled Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines, which updates some elements of the Adult Treatment Panel III (ATP III) cholesterol guidelines released in 2001. The ATP III update has been endorsed by the National Heart, Lung, and Blood Institute, the American Heart Association, and the American College of Cardiology. Based on a review of five clinical trials of cholesterol-lowering statin treatment that were conducted since the release of ATP III, the update offers options for more intensive cholesterol-lowering treatment for people at high risk and moderately-high risk for a heart attack.

The ATP III update emphasizes that therapeutic lifestyle changes--low saturated fat and low cholesterol diet, physical activity, and weight control--remain the cornerstone of treatment for lowering cholesterol levels.

The modifications in ATP III are as follows:

For high-risk patients--Individuals who have coronary heart disease (CHD) or disease of the blood vessels to the brain or extremities, or diabetes, or multiple (2 or more) risk factors that give them a greater than 20 percent chance of having a heart attack within 10 years:

• ATP III: The treatment goal for high-risk patients is an LDL less than 100 mg/dL.
  Update: The overall goal for high-risk patients is still an LDL less than 100 mg/dL. There is a therapeutic option to set the goal at an LDL less than 70 mg/dL for very high-risk patients--those who have had a recent heart attack, or those who have cardiovascular disease combined with either diabetes, or severe or poorly controlled risk factors (such as continued smoking), or metabolic syndrome (a cluster of risk factors associated with obesity that includes high triglycerides and low HDL cholesterol).
  
  
• ATP III: Recommended consideration of cholesterol-lowering drug treatment in addition to lifestyle therapy for LDL cholesterol levels 130 mg/dL or higher in high-risk patients. Characterized drug treatment for LDL levels 100-129 mg/dL as optional, and not needed for LDL less than 100 mg/dL.
  Update: Recommends consideration of drug treatment in addition to lifestyle therapy for LDL levels 100 mg/dL or higher in high-risk patients, and characterizes drug treatment as optional for LDL less than 100 mg/dL.

For moderately high-risk patients--Individuals who have multiple (2 or more) CHD risk factors together with a 10-20 percent risk for a heart attack within 10 years:

• ATP III: The treatment goal is an LDL less than 130 mg/dL, and drug treatment is recommended if LDL is 130 mg/dL or higher.
  Update: The overall goal for moderately high-risk patients is still an LDL less than 130 mg/dL. There is a therapeutic option to set the treatment goal at an LDL less than 100 mg/dL, and to use drug treatment if LDL is 100-129 mg/dL.

For high-risk and moderately high-risk patients:

• ATP III: Did not explicitly emphasize achieving a certain percentage lowering of LDL cholesterol.
  Update: Advises that the intensity of LDL-lowering drug treatment in high-risk and moderately high-risk patients be sufficient to achieve at least a 30 percent reduction in LDL levels.

For people who are at moderate risk--those with 2 or more risk factors plus a less than 10 percent risk for heart attack within 10 years, or lower risk--those with 0-1 risk factor, the update does not modify the ATP III recommendations.

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