Key Point: Recent clinical trials with statin therapy provide a rationale for lower target LDL-C levels and the use of more intensive LDL-C lowering therapy.

Since the NCEP ATP III Guidelines on cholesterol management were published in 2001, the results of 5 major clinical endpoint trials with statin therapy have been published. These studies examined issues that had not been adequately addressed in prior statin trials:

Heart Protection Study

PROSPER (Prospective Study of Pravastatin in the Elderly at Risk)

ALLHAT-LLT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial-Lipid Lowering Trial)

ASCOT-LLA (Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm)

PROVE-IT (Pravastatin or Atorvastatin Evaluation and Infection-Thrombolysis in Myocardial Infarction)

Based on the results of these trials, an expert panel has recommended the following key modifications to the current NCEP ATP III Guidelines:

In high-risk patients, the recommended LDL-C goal is <100 mg/dL

In high-risk patients, an LDL-C goal <70 mg/dL is a therapeutic option, especially for those patients considered to be at very high risk

The addition of a fibrate or nicotinic acid to LDL-C lowering therapy should be a consideration in high-risk patients with high triglyceride levels or low HDL-C levels

For patients at moderately high-risk, LDL-C goal <100 mg/dL is a therapeutic option

For high-risk or moderately high-risk patients, the intensity of LDL-C lowering therapy should be sufficient to achieve at least a 30% to 40% reduction in LDL-C levels

In addition, patients at high-risk or moderately high-risk with lifestyle-related risk factors (obesity, physical inactivity, elevated triglycerides, low HDL-C, or metabolic syndrome) should be considered candidates for TLC to modify these risk factors, regardless of their LDL-C levels

Reference

Grundy SM, Cleeman JI, Barey Merz N, et al. Implications of recent clinical trials for the National Cholesterol Education Program

Adult Treatment Panel III Guidelines. Circulation. 2004;110:227-239.