atp iii ncep

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Executive Summary of the Third Reportof the National Cholesterol Education Program(NCEP) Expert Panel on Detection, Evaluation,and Treatment of High Blood Cholesterolin Adults (Adult Treatment Panel III)Expert Panel on Detection,Evaluation, and Treatmentof High Blood Cholesterol in Adults

THE THIRD REPORT OF THE EX-pert Panel on Detection, Evalu-ation, and Treatment of HighBlood Cholesterol in Adults(Adult Treatment Panel III, or ATP III)constitutes the National CholesterolEducation Programs (NCEPs) up-dated clinical guidelines for choles-terol testing and management. The fullATP III document is an evidence-based and extensively referenced re-port that provides the scientific ratio-na le for the recommendat ionscontained in the executive summary.ATP III builds on previous ATP re-ports and expands the indications forintensive cholesterol-lowering therapyin clinical practice. It should be notedthat these guidelines are intended to in-form, not replace, the physicians clini-cal judgment, which must ultimatelydetermine the appropriate treatment foreach individual.

BACKGROUNDThe third ATP report updates the ex-isting recommendations for clinicalmanagement of high blood choles-terol. The NCEP periodically pro-duces ATP clinical updates as war-ranted by advances in the science ofcholesterol management. Each of theguideline reportsATP I, II, and III

has a major thrust. ATP I outlined astrategy for primary prevention of coro-nary heart disease (CHD) in personswith high levels of low-density lipo-protein (LDL) cholesterol ($160 mg/dL) or those with borderline high LDLcholesterol (130-159 mg/dL) and mul-tiple (2+) risk factors. ATP II affirmedthe importance of this approach andadded a new feature: the intensive man-agement of LDL cholesterol in per-sons with established CHD. For pa-tients with CHD, ATP II set a new,lower LDL cholesterol goal of #100 mg/dL. ATP III adds a call for more inten-sive LDL-lowering therapy in certaingroups of people, in accord with re-cent clinical trial evidence, but its coreis based on ATP I and ATP II. Some ofthe important features shared with pre-vious reports are shown in Table A inthe APPENDIX.

While ATP III maintains attention tointensive treatment of patients withCHD, its major new feature is a focuson primary prevention in persons withmultiple risk factors. Many of these per-sons have a relatively high risk for CHDand will benefit from more intensiveLDL-lowering treatment than recom-mended in ATP II. TABLE 1 shows thenew features of ATP III. (Note: To con-vert cholesterol to mmol/L, divide val-ues by 38.7).

LDL CHOLESTEROL: THEPRIMARY TARGET OF THERAPYResearch from experimental animals,laboratory investigations, epidemiol-

ogy, and genetic forms of hypercholes-terolemia indicate that elevated LDLcholesterol is a major cause of CHD. Inaddition, recent clinical trials robustlyshow that LDL-lowering therapy re-duces risk for CHD. For these rea-sons, ATP III continues to identify el-evated LDL cholesterol as the primarytarget of cholesterol-lowering therapy.As a result, the primary goals of therapyand the cutpoints for initiating treat-ment are stated in terms of LDL.

RISK ASSESSMENT: FIRST STEPIN RISK MANAGEMENTA basic principle of prevention is thatthe intensity of risk-reduction therapyshould be adjusted to a persons abso-lute risk. Hence, the first step in selec-tion of LDL-lowering therapy is toassess a persons risk status. Risk as-sessment requires measurement of LDLcholesterol as part of lipoprotein analy-sis and identification of accompany-ing risk determinants.

In all adults aged 20 years or older, afasting lipoprotein profile (total choles-terol, LDL cholesterol, high-density li-poprotein [HDL] cholesterol, and tri-glyceride) should be obtained once every5 years. If the testing opportunity is non-fasting, only the values for total choles-

Corresponding Author and Reprints: James I. Clee-man, MD, National Cholesterol Education Program,National Heart, Lung, and Blood Institute (NHLBI), 31Center Dr, Room 4A16, MSC 2480, Bethesda, MD20892-2480 (e-mail: [email protected]).The Full Report of ATP III is available online on theNHLBI Web site at www.nhlbi.nih.gov.Members of the NCEP Expert Panel are listed at theend of this article.

See also p 2508 and Patient Page.

2486 JAMA, May 16, 2001Vol 285, No. 19 (Reprinted) 2001 American Medical Association. All rights reserved.

terol and HDL cholesterol will be us-able. In such a case, if total cholesterolis $200 mg/dL or HDL is ,40 mg/dL,a follow-up lipoprotein profile is neededfor appropriate management based onLDL. The relationship between LDL cho-lesterol levels and CHD risk is continu-ous over a broad range of LDL levelsfrom low to high. Therefore, ATP IIIadopts the classification of LDL choles-terol levels shown in TABLE 2, which alsoshows the classification of total and HDLcholesterol levels.

Risk determinants in addition to LDLcholesterol include the presence or ab-sence of CHD, other clinical forms ofatherosclerotic disease, and the majorrisk factors other than LDL (TABLE 3).(LDL is not counted among the risk fac-tors in Table 3 because the purpose ofcounting those risk factors is to modifythe treatment of LDL.) Based on theseother risk determinants, ATP III iden-tifies 3 categories of risk that modify thegoals and modalities of LDL-loweringtherapy. TABLE 4 defines these catego-ries of risk and shows correspondingLDL cholesterol goals.

The category of highest risk con-sists of CHD and CHD risk equiva-lents. The latter carry a risk for majorcoronary events equal to that of estab-lished CHD, ie, .20% per 10 years (ie,more than 20 of 100 such individualswill develop CHD or have a recurrentCHD event within 10 years). CHD riskequivalents comprise:

Other clinical forms of athero-sclerotic disease (peripheral arterialdisease, abdominal aortic aneurysm,and symptomatic carotid arterydisease)

Diabetes Multiple risk factors that confer a

10-year risk for CHD .20%.Diabetes counts as a CHD risk

equivalent because it confers a high riskof new CHD within 10 years, in part be-cause of its frequent association withmultiple risk factors. Furthermore, be-cause persons with diabetes who ex-perience a myocardial infarction havean unusually high death rate either im-mediately or in the long term, a moreintensive prevention strategy is war-

ranted. Persons with CHD or CHD riskequivalents have the lowest LDL cho-lesterol goal (,100 mg/dL).

The second category consists of per-sons with multiple (2+) risk factors inwhom 10-year risk for CHD is #20%.Risk is estimated from Framingham riskscores (see Appendix). The major riskfactors, exclusive of elevated LDL cho-lesterol, are used to define the pres-ence of multiple risk factors that modifythe goals and cutpoints for LDL-lowering treatment, and these are listedin Table 3. The LDL cholesterol goal forpersons with multiple (2+) risk fac-tors is ,130 mg/dL.

The third category consists of per-sons having 0-1 risk factor; with few ex-ceptions, persons in this category havea 10-year risk ,10%. Their LDL cho-lesterol goal is ,160 mg/dL.

Method of Risk Assessment:Counting Major Risk Factors andEstimating 10-Year CHD RiskRisk status in persons without clini-cally manifest CHD or other clinicalforms of atherosclerotic disease is de-termined by a 2-step procedure. First,the number of risk factors is counted(Table 3). Second, for persons withmultiple (2+) risk factors, 10-year riskassessment is carried out with Framing-ham scoring (see Appendix) to iden-tify individuals whose short-term (10-

Table 2. ATP III Classification of LDL, Total,and HDL Cholesterol (mg/dL)*

LDL cholesterol,100 Optimal100-129 Near or above optimal130-159 Borderline high160-189 High$190 Very high

Total cholesterol,200 Desirable200-239 Borderline high$240 High

HDL cholesterol,40 Low$60 High

*ATP indicates Adult Treatment Panel; LDL, low-densitylipoprotein; and HDL, high-density lipoprotein.

Table 4. Three Categories of Risk ThatModify LDL Cholesterol Goals

Risk CategoryLDL Goal(mg/dL)

CHD and CHD risk equivalents ,100Multiple (2+) risk factors* ,1300-1 risk factor ,160

*Risk factors that modify the low-density lipoprotein (LDL)goal are listed in Table 3. CHD indicates coronary heartdisease.

Table 3. Major Risk Factors (Exclusive ofLDL Cholesterol) That Modify LDL Goals*

Cigarette smoking Hypertension (blood pressure $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 femalefirst-degree relative ,65 years)

Age (men $45 years; women $55 years)

*Diabetes is regarded as a coronary heart disease (CHD)risk equivalent. LDL indicates low-density lipoprotein;HDL, high-density lipoprotein.

HDL cholesterol $60 mg/dL counts as a negative riskfactor; its presence removes 1 risk factor from the totalcount.

Table 1. New Features of ATP III*

Focus on Multiple Risk Factors Raises persons with diabetes without CHD, most of whom have multiple risk factors, to the risk level

of CHD risk equivalent Uses Framingham projections of 10-year absolute CHD risk (ie, the percent probability of having a

CHD event in 10 years) to identify certain patients with multiple (2+) risk factors for more intensivetreatment

Identifies persons with multiple metabolic risk factors (metabolic syndrome) as candidates forintensified therapeutic lifestyle changes

Modifications of Lipid and Lipoprotein Classification Identifies LDL cholesterol ,100 mg/dL as optimal Raises categorical low HDL cholesterol from ,35 mg/dL to ,40 mg/dL because the latter is a better

measure of a depressed HDL Lowers the triglyceride classification cutpoints to give more attention to moderate elevations

Support for Implementation Recommends a complete lipoprotein profile (total, LDL, and HDL cholesterol and triglycerides) as

the preferred initial test, rather than screening for total cholesterol and HDL alone Encourages use of plant stanols/sterols and viscous (soluble) fiber as therapeutic dietary options to

enhance lowering of LDL cholesterol Presents strategies for promoting adherence to therapeutic lifestyle changes and drug therapies Recommends treatment beyond LDL lowering for persons with triglycerides $200 mg/dL

*ATP indicates Adult Treatment Panel; CHD, coronary heart disease; LDL, low-density lipoprotein; and HDL, high-density lipoprotein.

SUMMARY OF THE NCEP ADULT TREATMENT PANEL III REPORT

2001 American Medical Association. All rights reserved. (Reprinted) JAMA, May 16, 2001Vol 285, No. 19 2487

year) risk warrants consideration ofintensive treatment. Estimation of the10-year CHD risk adds a step to risk as-sessment beyond risk factor counting,but this step is warranted because it al-lows better targeting of intensive treat-ment to people who will benefit fromit. When 0-1 risk factor is present,Framingham scoring is not necessarybecause 10-year risk rarely reaches lev-els for intensive intervention; a veryhigh LDL level in such a person maynevertheless warrant consideration ofdrug therapy to reduce long-term risk.Risk factors used in Framingham scor-ing include age, total cholesterol, HDLcholesterol, blood pressure, and ciga-rette smoking. Total cholesterol is usedfor 10-year risk assessment because ofa larger and more robust Framinghamdatabase for total than for LDL choles-terol, but LDL cholesterol is the pri-mary target of therapy. Framinghamscoring divides persons with multiplerisk factors into those with 10-year riskfor CHD of .20%, 10%-20%, and,10%. It should be noted that this2-step sequence can be reversed withessentially the same results. (IfFramingham scoring is carried out be-fore risk factor counting, persons with,10% risk are then divided into thosewith 2+ risk factors and 0-1 risk factorby risk factor counting to determine theappropriate LDL goal [Table 4].) Ini-tial risk assessment in ATP III uses themajor risk factors to define the core riskstatus. Only after the core risk statushas been determined should any otherrisk modifiers be taken into consider-ation for adjusting the therapeuticapproach.

Role of Other Risk Factorsin Risk AssessmentATP III recognizes that risk for CHDis influenced by other factors not in-cluded among the major, independentrisk factors (Table 3). Among these arelife-habit risk factors and emerging riskfactors. The former include obesity,physical inactivity, and atherogenic diet;the latter consist of lipoprotein(a),homocysteine, prothrombotic and pro-inflammatory factors, impaired fast-

ing glucose, and evidence of subclini-cal atherosclerotic disease. The life-habit risk factors are direct targets forclinical intervention but are not usedto set a lower LDL cholesterol goal oftherapy. The emerging risk factors donot categorically modify LDL choles-terol goals; however, they appear tocontribute to CHD risk to varying de-grees and can have utility in selectedpersons to guide intensity of risk-reduction therapy. Their presence canmodulate clinical judgment when mak-ing therapeutic decisions.

Metabolic SyndromeMany persons have a constellation ofmajor risk factors, life-habit risk fac-tors, and emerging risk factors that con-stitute a condition called the meta-bolic syndrome. Factors characteristicof the metabolic syndrome are abdomi-nal obesity, atherogenic dyslipidemia(elevated triglyceride, small LDL par-ticles, low HDL cholesterol), raisedblood pressure, insulin resistance (withor without glucose intolerance), andprothrombotic and proinflammatorystates. ATP III recognizes the meta-bolic syndrome as a secondary target ofrisk-reduction therapy, after the pri-mary targetLDL cholesterol. Diag-nosis and treatment of the metabolicsyndrome is described below underBenefit Beyond LDL Lowering: TheMetabolic Syndrome as a SecondaryTarget of Therapy.

The Link Between Risk Assessmentand Cost-effectivenessIn ATP III, a primary aim is to matchintensity of LDL-lowering therapywith absolute risk. Everyone withelevated LDL cholesterol is treatedwith lifestyle changes that are effectivein lowering LDL levels. Persons atrelatively high risk are also candidatesfor drug treatment, which is veryeffective but entails significant addi-tional expense. The cutpoints for drugtreatment are based primarily on risk-benefit considerations: those at higherrisk are likely to get greater benefit.However, cutpoints for recommendedmanagement based on therapeutic effi-

cacy are checked against currentlya c c e p t e d s t a n d a r d s f o r c o s t -effectiveness. Lifestyle changes are themost cost-effective means to reducerisk for CHD. Even so, to achievemaximal benefit, many persons willrequire LDL-lowering drugs. Drugtherapy is the major expense of LDL-lowering therapy and it dominatescost-effectiveness analysis. However,the costs of LDL-lowering drugs arecurrently in flux and appear to bedeclining. This report recognizes thatas drug prices decline it will be pos-sible to extend drug use to lower-riskpersons and still be cost-effective. Inaddition, ATP III recognizes that somepersons with high long-term risk arecandidates for LDL-lowering drugseven though use of drugs may not becost-effective by current standards.

PRIMARY PREVENTION WITHLDL-LOWERING THERAPYPrimary prevention of CHD offers thegreatest opportunity for reducing theburden of CHD in the United States.The clinical approach to primary pre-vention is founded on the publichealth approach that calls for lifestylechanges, including (1) reducedintakes of saturated fat and choles-terol, (2) increased physical activity,and (3) weight control, to lower popu-lation cholesterol levels and reduceCHD risk, but the clinical approachintensifies preventive strategies forhigher-risk persons. One aim of pri-mary prevention is to reduce long-term risk (.10 years) as well as short-term risk (#10 years). LDL goals inprimary prevention depend on a per-sons absolute risk for CHD (ie, theprobability of having a CHD event inthe short term or the long term)thehigher the risk, the lower the goal.Therapeutic lifestyle changes are thefoundation of clinical primary preven-tion. Nonetheless, some persons athigher risk because of high or veryhigh LDL cholesterol levels or becauseof multiple risk factors are candidatesfor LDL-lowering drugs. Recent pri-mary prevention trials show that LDL-lowering drugs reduce risk for major



coronary events and coronary deatheven in the short term.

Any person with elevated LDL cho-lesterol or other form of hyperlipid-emia should undergo clinical orlaboratory assessment to rule outsecondary dyslipidemia before initia-tion of lipid-lowering therapy. Causesof secondary dyslipidemia include: Diabetes Hypothyroidism Obstructive liver disease Chronic renal failure Drugs that increase LDL choles-

terol and decrease HDL choles-terol (progestins, anabolic ste-roids, and corticosteroids).

Once secondary causes have been ex-cluded or, if appropriate, treated, thegoals for LDL-lowering therapy in pri-mary prevention are established ac-cording to a persons risk category(Table 4).

SECONDARY PREVENTIONWITH LDL-LOWERINGTHERAPYRecent clinical trials demonstratethat LDL-lowering therapy reducestotal mortality, coronary mortality,major coronary events, coronaryartery procedures, and stroke in per-sons with established CHD. Asshown in Table 2, an LDL cholesterollevel of ,100 mg/dL is optimal;therefore, ATP III specifies an LDLcholesterol level of ,100 mg/dL asthe goal of therapy in secondary pre-vention. This goal is supported byclinical trials with both clinical andangiographic end points and by pro-spective epidemiological studies. Thesame goal should apply for personswith CHD risk equivalents. Whenpersons are hospitalized for acutecoronary syndromes or coronary pro-cedures, lipid measures should betaken on admission or within 24hours. These values can guide thephysician on initiation of LDL-lowering therapy before or at dis-charge. Adjustment of therapy maybe needed after 12 weeks.

LDL-LOWERING THERAPYIN 3 RISK CATEGORIESThe 2 major modalities of LDL-lowering therapy are therapeutic life-style changes (TLC) and drug therapy.Both are described in more detail later.The TLC Diet stresses reductions insaturated fat and cholesterol intakes.When the metabolic syndrome or its as-sociated lipid risk factors (elevated tri-glyceride or low HDL cholesterol) arepresent, TLC also stresses weight re-duction and increased physical activ-ity. TABLE 5 defines LDL cholesterolgoals and cutpoints for initiation of TLCand for drug consideration for per-sons with 3 categories of risk: CHD andCHD risk equivalents; multiple (2+) riskfactors (10-year risk 10%-20% and,10%); and 0-1 risk factor.

CHD and CHD Risk EquivalentsFor persons with CHD and CHD riskequivalents, LDL-lowering therapygreatly reduces risk for major coro-nary events and stroke and yields highlyfavorable cost-effectiveness ratios. Thecutpoints for initiating lifestyle and drugtherapies are shown in Table 5.

If baseline LDL cholesterol is 130 mg/dL, intensive lifestyle therapy and maxi-mal control of other risk factors shouldbe started. Moreover, for most pa-tients, an LDL-lowering drug will be re-quired to achieve an LDL cholesterollevel of ,100 mg/dL; thus an LDL-cholesterol lowering drug can be startedsimultaneously with TLC to attain thegoal of therapy.

If LDL cholesterol levels are 100-129mg/dL, either at baseline or on LDL-lowering therapy, several therapeuticapproaches are available:

Initiate or intensify lifestyle and/ordrug therapies specifically to lower LDL.

Emphasize weight reduction andincreased physical activity in personswith the metabolic syndrome.

Delay use or intensification of LDL-lowering therapies and institute treat-ment of other lipid or nonlipid risk fac-tors; consider use of other lipid-modifying drugs (eg, nicotinic acid orfibric acid) if the patient has elevatedtriglyceride or low HDL cholesterol.

If baseline LDL cholesterol is

is ,160 mg/dL on TLC alone, it shouldbe continued. LDL-lowering drugs gen-erally are not recommended because thepatient is not at high short-term risk.On the other hand, if LDL cholesterolis $160 mg/dL, drug therapy can beconsidered to achieve an LDL choles-terol level of ,130 mg/dL; the pri-mary aim is to reduce long-term risk.Cost-effectiveness is marginal, but drugtherapy can be justified to slow devel-opment of coronary atherosclerosis andto reduce long-term risk for CHD.

0-1 Risk FactorMost persons with 0-1 risk factor have a10-year risk ,10%. They are managedaccording to Table 5. The goal for LDLcholesterol in this risk category is ,160mg/dL. The primary aim of therapy is toreduce long-term risk. First-line therapyis TLC. If after 3 months of TLC the LDLcholesterol is ,160 mg/dL, TLC is con-tinued. However, if LDL choles-

terol is 160-189 mg/dL after an ad-equate trial of TLC, drug therapy is op-tional depending on clinical judgment.Factors favoring use of drugs include:

A severe single risk factor (heavycigarette smoking, poorly controlled hy-pertension, strong family history of pre-mature CHD, or very low HDL choles-terol)

Multiple life-habit risk factors andemerging risk factors (if measured)

10-year risk approaching 10% (ifmeasured; see Appendix). If LDL cho-lesterol is $190 mg/dL despite TLC,drug therapy should be considered toachieve the LDL goal of ,160 mg/dL.

The purpose of using LDL-loweringdrugs in persons with 0-1 risk factor andelevated LDL cholesterol ($160 mg/dL) is to slow the development of coro-nary atherosclerosis, which will re-duce long-term risk. This aim mayconflict with cost-effectiveness consid-erations; thus, clinical judgment is re-

quired in selection of persons for drugtherapy, although a strong case can bemade for using drugs when LDL cho-lesterol is $190 mg/dL after TLC.

For persons whose LDL cholesterollevels are already below goal levels uponfirst encounter, instructions for appro-priate changes in life habits, periodicfollow-up, and control of other risk fac-tors are needed.

THERAPEUTIC LIFESTYLECHANGES IN LDL-LOWERINGTHERAPYATP III recommends a multifaceted life-style approach to reduce risk for CHD.This approach is designated therapeu-tic lifestyle changes (TLC). Its essen-tial features are:

Reduced intakes of saturated fats(,7% of total calories) and choles-terol (,200 mg/d) (see TABLE 6 foroverall composition of the TLC Diet)

Therapeutic options for enhanc-ing LDL lowering such as plant stanols/sterols (2 g/d) and increased viscous(soluble) fiber (10-25 g/d)

Weight reduction Increased physical activity.A model of steps in TLC is shown in

FIGURE 1. To initiate TLC, intakes ofsaturated fats and cholesterol are re-duced first to lower LDL cholesterol. Toimprove overall health, ATP IIIs TLCDiet generally contains the recommen-dations embodied in the Dietary Guide-lines for Americans 2000. One excep-tion is that total fat is allowed to rangefrom 25%-35% of total calories pro-vided saturated fats and trans fatty ac-ids are kept low. A higher intake of to-tal fat, mostly in the form of unsaturatedfat, can help to reduce triglycerides andraise HDL cholesterol in persons withthe metabolic syndrome. In accord withthe Dietary Guidelines, moderate physi-cal activity is encouraged. After 6 weeks,the LDL response is determined; if theLDL cholesterol goal has not beenachieved, other therapeutic options forLDL lowering such as plant stanol/sterols and viscous fiber can be added.

After maximum reduction of LDLcholesterol with dietary therapy, em-phasis shifts to management of the

Table 5. LDL Cholesterol Goals and Cutpoints for Therapeutic Lifestyle Changes (TLC) andDrug Therapy in Different Risk Categories*

Risk CategoryLDL Goal(mg/dL)

LDL Level at Which toInitiate TherapeuticLifestyle Changes

(mg/dL)

LDL Level at Which toConsider Drug

Therapy (mg/dL)

CHD or CHD risk equivalents(10-year risk .20%)

,100 $100 $130(100-129: drug optional)

2+ Risk factors,130 $130

10-year risk 10%-20%: $130(10-year risk #20%) 10-year risk ,10%: $160

0-1 Risk factor ,160 $160 $190(160-189: LDL-lowering

drug optional)

*LDL indicates low-density lipoprotein; CHD, coronary heart disease.Some authorities recommend use of LDL-lowering drugs in this category if an LDL cholesterol level of ,100 mg/dL

cannot be achieved by therapeutic lifestyle changes. Others prefer use of drugs that primarily modify triglyceridesand HDL, eg, nicotinic acid or fibrate. Clinical judgment also may call for deferring drug therapy in this subcategory.

Almost all people with 0-1 risk factor have a 10-year risk ,10%; thus, 10-year risk assessment in people with 0-1 riskfactor is not necessary.

Table 6. Nutrient Composition of the Therapeutic Lifestyle Changes (TLC) Diet

Nutrient Recommended Intake

Saturated fat* ,7% of total caloriesPolyunsaturated fat Up to 10% of total caloriesMonounsaturated fat Up to 20% of total caloriesTotal fat 25%-35% of total caloriesCarbohydrate 50%-60% of total caloriesFiber 20-30 g/dProtein Approximately 15% of total caloriesCholesterol ,200 mg/dTotal calories Balance energy intake and expenditure to maintain

desirable body weight/prevent weight gain

*Trans fatty acids are another LDL-raising fat that should be kept at a low intake.Carbohydrates should be derived predominantly from foods rich in complex carbohydrates including grains, espe-

cially whole grains, fruits, and vegetables.Daily energy expenditure should include at least moderate physical activity (contributing approximately 200 kcal/d).



metabolic syndrome and associatedlipid risk factors. The majority of per-sons with these latter abnormalities areoverweight or obese and sedentary.Weight reduction therapy for over-weight or obese patients will enhanceLDL lowering and will provide otherhealth benefits including modifyingother lipid and nonlipid risk factors. As-sistance in the management of over-weight and obese persons is providedby the Clinical Guidelines on the Iden-tification, Evaluation, and Treatment ofOverweight and Obesity in Adults fromthe NHLBI Obesity Education Initia-tive (1998). Additional risk reduction

can be achieved by simultaneously in-creasing physical activity.

At all stages of dietary therapy, phy-sicians are encouraged to refer pa-tients to registered dietitians or otherqualified nutritionists for medical nu-trition therapy, which is the term for thenutritional intervention and guidanceprovided by a nutrition professional.

DRUG THERAPY TO ACHIEVELDL CHOLESTEROL GOALSA portion of the population whoseshort-term or long-term risk for CHDis high will require LDL-lowering drugsin addition to TLC to reach the desig-

nated goal for LDL cholesterol (seeTable 5). When drugs are prescribed,attention to TLC should always bemaintained and reinforced. Currentlyavailable drugs that affect lipoproteinmetabolism and their major character-istics are listed in TABLE 7.

Some cholesterol-lowering agents arecurrently available over-the-counter(OTC) (eg, nicotinic acid), and manu-facturers of several classes of LDL-lowering drugs (eg, statins, bile acidsequestrants) have applied to the FoodandDrugAdministration(FDA)toallowthese agents to become OTC medica-tions. At the time of publication of ATPIII, the FDA has not granted permissionfor OTC status for statins or bile acidsequestrants. If an OTC cholesterol-lowering drug is or becomes available,patients should continue to consult withtheir physicians about whether to ini-tiate drug treatment, about setting thegoals of therapy, and about monitoringfor therapeutic responsesandsideeffects.

Secondary Prevention:Drug Therapy for CHDand CHD Risk EquivalentsFor persons with CHD and CHD riskequivalents, the goal is to attain an LDLcholesterol level of ,100 mg/dL. Thecutpoints for initiating lifestyle and drug

Figure 1. Model of Steps in Therapeutic Lifestyle Changes (TLC)

Visit 3Evaluate LDL

Response

If LDL Goal NotAchieved,Consider Adding Drug Therapy

Visit NMonitor Adherence

to TLC

Visit 1Begin Lifestyle

Therapies 6Weeks

6Weeks

Every4-6

Months

Emphasize Reductionof Saturated Fatand CholesterolIntakes

Encourage ModeratePhysical Activity

Consider Referral to aDietitian

Reinforce Reductionin Saturated Fat andCholesterol Intakes

Consider AddingPlant Stanols/Sterols

Increase Fiber Intake Consider Referral

to a Dietitian

Initiate Therapy forMetabolicSyndrome

Intensify WeightManagement andPhysical Activity

Consider Referral to a Dietitian

Visit 2Evaluate LDL

Response

If LDL Goal NotAchieved,Intensify LDL-LoweringTherapy

LDL indicates low-density lipoprotein.

Table 7. Drugs Affecting Lipoprotein Metabolism*

Drug Class, Agents,and Daily Doses

Lipid/LipoproteinEffects Side Effects Contraindications Clinical Trial Results

HMG-CoA reductaseinhibitors(statins)

LDL fl 18%-55%HDL 5%-15%TG fl 7%-30%

Myopathy; increasedliver enzymes

Absolute: active or chronicliver disease

Relative: concomitant useof certain drugs

Reduced major coronaryevents, CHD deaths, needfor coronary procedures,stroke, and total mortality

Bile acidsequestrants

LDL fl 15%-30%HDL 3%-5%TG No change or

increase

Gastrointestinal distress;constipation;decreased absorptionof other drugs

Absolute: dysbetalipoproteinemia;TG .400 mg/dL

Relative:TG .200 mg/dL

Reduced major coronary eventsand CHD deaths

Nicotinic acid\ LDL fl 5%-25%HDL 15%-35%TG fl 20%-50%

Flushing; hyperglycemia;hyperuricemia (or gout);upper gastrointestinaldistress; hepatotoxicity

Absolute: chronic liver disease;severe gout

Relative: diabetes; hyperuricemia;peptic ulcer disease

Reduced major coronary events,and possibly total mortality

Fibric acids LDL fl 5%-20%(may be increased inpatients with high TG)

HDL 10%-20%TG fl 20%-50%

Dyspepsia; gallstones;myopathy; unexplainednon-CHD deaths inWHO study

Absolute: severe renal disease;severe hepatic disease

Reduced major coronary events

*HMG-CoA indicates 3-hydroxy-3-methylglutaryl coenzyme A; LDL, low-density lipoprotein; HDL, high-density lipoprotein; TG, triglycerides; fl , decrease; , increase; and CHD,coronary heart disease.

Lovastatin (20-80 mg), pravastatin (20-40 mg), simvastatin (20-80 mg), fluvastatin (20-80 mg), atorvastatin (10-80 mg), and cerivastatin (0.4-0.8 mg).Cholestyramine (4-16 g), colestipol (5-20 g), and colesevelam (2.6-3.8 g).Cyclosporine, macrolide antibiotics, various antifungal agents, and cytochrome P-450 inhibitors (fibrates and niacin should be used with appropriate caution).\ Immediate-release (crystalline) nicotinic acid (1.5-3 g), extended-release nicotinic acid (1-2 g), and sustained-release nicotinic acid (1-2 g).Gemfibrozil (600 mg twice daily), fenofibrate (200 mg), and clofibrate (1000 mg twice daily).



therapies are shown in Table 5. Mostpatients with CHD will need LDL-lowering drug therapy. Other lipid riskfactors may also warrant consider-ation of drug treatment. Whether or notlipid-modifying drugs are used, non-lipid risk factors require attention andfavorable modification.

In patients admitted to the hospitalfor a major coronary event, LDL cho-lesterol should be measured on admis-sion or within 24 hours. This value canbe used for treatment decisions. In gen-eral, persons hospitalized for a coro-nary event or procedure should be dis-charged on drug therapy if the LDLcholesterol is $130 mg/dL. If the LDLis 100-129 mg/dL, clinical judgmentshould be used in deciding whether toinitiate drug treatment at discharge, rec-ognizing that LDL cholesterol levels be-gin to decline in the first few hours af-ter an event and are significantlydecreased by 24 to 48 hours and mayremain low for many weeks. Thus, theinitial LDL cholesterol level obtainedin the hospital may be substantiallylower than is usual for the patient. Someauthorities hold that drug therapyshould be initiated whenever a patienthospitalized for a CHD-related illnessis found to have an LDL cholesterol.100 mg/dL. Initiation of drug therapyat the time of hospital discharge has 2advantages. First, at that time patientsare particularly motivated to under-take and adhere to risk-lowering inter-ventions; and second, failure to ini-tiate indicated therapy early is one ofthe causes of a large treatment gap,because outpatient follow-up is oftenless consistent and more fragmented.

LDL-Lowering Drug Therapyfor Primary PreventionTable 5 shows the cutpoints for con-sidering drug treatment in primary pre-vention. The general approach to man-agement of drug therapy for primaryprevention is outlined in FIGURE 2.

When drug therapy for primary pre-vention is a consideration, the third visitof dietary therapy (see Figure 1) willtypically be the visit to initiate drugtreatment. Even if drug treatment isstarted, TLC should be continued. Aswith TLC, the first priority of drugtherapy is to achieve the goal for LDLcholesterol. For this reason, an LDL-lowering drug should be started. Theusual drug will be a statin, but alterna-tives are a bile acid sequestrant or nico-tinic acid. In most cases, the statinshould be started at a moderate dose.In many patients, the LDL cholesterolgoal will be achieved, and higher doseswill not be necessary. The patients re-sponse should be evaluated about 6weeks after starting drug therapy. If thegoal of therapy has been achieved, thecurrent dose can be maintained. How-ever, if the goal has not been achieved,LDL-lowering therapy can be intensi-fied, either by increasing the dose ofstatin or by combining a statin with abile acid sequestrant or nicotinic acid.

After 12 weeks of drug therapy, theresponse to therapy should again be as-sessed. If the LDL cholesterol goal is stillnot achieved, consideration can begiven to further intensification of drugtherapy. If the LDL goal cannot be at-tained by standard lipid-loweringtherapy, consideration should be givento seeking consultation from a lipid spe-

cialist. Once the goal for LDL choles-terol has been attained, attention canturn to other lipid risk factors and non-lipid factors. Thereafter, patients can bemonitored for response to therapy ev-ery 4 to 6 months, or more often if con-sidered necessary.

BENEFIT BEYOND LDLLOWERING: THE METABOLICSYNDROME AS A SECONDARYTARGET OF THERAPYEvidence is accumulating that risk forCHD can be reduced beyond LDL-lowering therapy by modification ofother risk factors. One potential sec-ondary target of therapy is the meta-bolic syndrome, which represents aconstellation of lipid and nonlipid riskfactors of metabolic origin. This syn-drome is closely linked to a general-ized metabolic disorder called insulinresistance in which the normal actionsof insulin are impaired. Excess body fat(particularly abdominal obesity) andphysical inactivity promote the devel-opment of insulin resistance, but someindividuals also are genetically predis-posed to insulin resistance.

The risk factors of the metabolic syn-drome are highly concordant; in aggre-gate they enhance risk for CHD at anygiven LDL cholesterol level. For pur-poses of ATP III, the diagnosis of themetabolic syndrome is made when 3 ormore of the risk determinants shownin TABLE 8 are present. These determi-nants include a combination of cat-egorical and borderline risk factors thatcan be readily measured in clinicalpractice.

Management of the metabolic syn-drome has a 2-fold objective: (1) to re-duce underlying causes (ie, obesity andphysical inactivity) and (2) to treatassociated nonlipid and lipid riskfactors.

Management of Underlying Causesof the Metabolic SyndromeFirst-line therapies for all lipid and non-lipid risk factors associated with themetabolic syndrome are weight reduc-tion and increased physical activity,

Figure 2. Progression of Drug Therapy in Primary Prevention

6Weeks

6Weeks

Every4-6

Months

Start Statinor

Bile AcidSequestrant

orNicotinic Acid

Consider HigherDose of Statin

orAdd Bile AcidSequestrant orNicotinic Acid

If LDL Goal NotAchieved, Intensify Drug Therapy orRefer to a LipidSpecialist

If LDL Goal Achieved,Treat Other LipidRisk Factors

Monitor Responseand Adherenceto Therapy

If LDL Goal NotAchieved,Intensify LDL-Lowering DrugTherapy

Initiate LDL-LoweringDrug Therapy

LDL indicates low-density lipoprotein.



which will effectively reduce all of theserisk factors. Therefore, after appropri-ate control of LDL cholesterol, TLCshould stress weight reduction andphysical activity if the metabolic syn-drome is present.

Weight Control. In ATP III over-weight and obesity are recognized asmajor, underlying risk factors for CHDand identified as direct targets of inter-vention. Weight reduction will en-hance LDL lowering and reduce allof the risk factors of the metabolicsyndrome. The recommended ap-proaches for reducing overweight andobesity are contained in the clinicalguidelines of the Obesity Education Ini-tiative.

Physical Activity. Physical inactivityis likewise a major, underlying risk fac-tor for CHD. It augments the lipid andnonlipid risk factors of the metabolicsyndrome. It further may enhance riskby impairing cardiovascular fitness andcoronary blood flow. Regular physicalactivity reduces very low-density lipo-protein (VLDL) levels, raises HDL cho-lesterol, and in some persons, lowersLDL levels. It also can lower blood pres-sure, reduce insulin resistance, and fa-vorably influence cardiovascular func-tion. Thus, ATP III recommends thatregular physical activity become a rou-tine component in management of highserum cholesterol. The evidence basefor this recommendation is containedin the US Surgeon Generals Report onPhysical Activity.

Specific Treatment of Lipidand Nonlipid Risk FactorsBeyond the underlying risk factors,therapies directed against the lipid andnonlipid risk factors of the metabolicsyndrome will reduce CHD risk. Theseinclude treatment of hypertension, useof aspirin in patients with CHD to re-duce the prothrombotic state (guide-lines for aspirin use in primary preven-tion have not been firmly established),and treatment of elevated triglycer-ides and low HDL cholesterol as dis-cussed below under Management ofSpecific Dyslipidemias.

SPECIAL ISSUESManagement of SpecificDyslipidemiasVery High LDL Cholesterol ( 190mg/dL). Persons with very high LDL cho-lesterol usually have genetic forms ofhypercholesterolemia: monogenic famil-ial hypercholesterolemia, familial defec-tive apolipoprotein B, and polygenic hy-percholesterolemia. Early detection ofthese disorders through cholesterol test-ing in young adults is needed to pre-vent premature CHD. Family testingis important to identify similarlyaffected relatives. These disorders oftenrequire combined drug therapy(statin+bile acid sequestrant) to achievethe goals of LDL-lowering therapy.

Elevated Serum Triglycerides. Recentmeta-analysesofprospectivestudies indi-cate that elevated triglycerides are alsoan independent risk factor forCHD.Fac-torscontributingtoelevated(higher thannormal)triglycerides inthegeneralpopu-lation include obesity and overweight,physical inactivity, cigarette smoking,excess alcohol intake, high-carbohy-dratediets (.60%ofenergy intake), sev-eral diseases (eg, type 2 diabetes, chronicrenal failure, nephrotic syndrome), cer-tain drugs (eg, corticosteroids, estro-gens, retinoids, higher doses of b-adren-ergic blocking agents), and geneticdisorders (familial combined hyperlip-idemia, familialhypertriglyceridemia,andfamilial dysbetalipoproteinemia).

In clinical practice, elevated serumtriglycerides are most often observed inpersons with the metabolic syndrome,although secondary or genetic factorscan heighten triglyceride levels. ATP IIIadopts the following classification of se-rum triglycerides:

Normal triglycerides: ,150 mg/dL Borderline-high triglycerides:

150-199 mg/dL High triglycerides: 200-499 mg/dL Very h igh t r i g l yce r ides :

$500 mg/dL(To convert triglyceride values to

mmol/L, divide by 88.6.)The finding thatelevated triglycerides

arean independentCHDrisk factor sug-gests thatsometriglyceride-rich lipopro-teins are atherogenic. The latter are par-

tially degraded VLDL, commonly calledremnant lipoproteins. Inclinicalpractice,VLDLcholesterolisthemostreadilyavail-able measure of atherogenic remnantlipoproteins. Thus, VLDL cholesterolcan be a target of cholesterol-loweringtherapy. ATP III identifies the sum ofLDL+VLDL cholesterol (termed non-HDL cholesterol [total cholesterolHDLcholesterol]) as a secondary target oftherapy in persons with high triglycer-ides ($200 mg/dL). The goal for non-HDLcholesterol inpersonswithhighse-rum triglycerides can be set at 30 mg/dLhigher than that for LDL cholesterol(TABLE 9) on the premise that a VLDLcholesterol level #30 mg/dL is normal.

Thetreatmentstrategyforelevatedtri-glycerides depends on the causes of theelevationandits severity.Forallpersons

Table 8. Clinical Identification of theMetabolic Syndrome

Risk Factor Defining Level

Abdominal obesity*(waist circumference)

Men .102 cm (.40 in)Women .88 cm (.35 in)

Triglycerides $150 mg/dL High-density lipoprotein

cholesterolMen ,40 mg/dLWomen ,50 mg/dL

Blood pressure $130/$85 mm Hg Fasting glucose $110 mg/dL

*Overweight and obesity are associated with insulin re-sistance and the metabolic syndrome. However, thepresence of abdominal obesity is more highly corre-lated with the metabolic risk factors than is an elevatedbody mass index (BMI). Therefore, the simple measureof waist circumference is recommended to identify thebody weight component of the metabolic syndrome.

Some male patients can develop multiple metabolic riskfactors when the waist circumference is only margin-ally increased, eg, 94-102 cm (37-40 in). Such pa-tients may have strong genetic contribution to insulinresistance and they should benefit from changes in lifehabits, similarly to men with categorical increases in waistcircumference.

Table 9. Comparison of LDL Cholesteroland Non-HDL Cholesterol Goals for 3 RiskCategories*

Risk Category

LDLGoal

(mg/dL)

Non-HDLGoal

(mg/dL)

CHD and CHDrisk equivalent(10-year risk forCHD .20%)

,100 ,130

Multiple (2+) risk factorsand 10-year risk #20%

,130 ,160

0-1 Risk factor ,160 ,190

*LDL indicates low-density lipoprotein; HDL, high-density lipoprotein; and CHD, coronary heart disease.



with borderline high or high triglycer-ides, the primary aim of therapy is toachieve the target goal for LDL choles-terol. When triglycerides are borderlinehigh(150-199mg/dL),emphasis shouldalso be placed on weight reduction andincreased physical activity. For high tri-glycerides (200-499 mg/dL), non-HDLcholesterol becomes a secondary targetof therapy.Aside fromweight reductionand increased physical activity, drugtherapy can be considered in high-riskpersons toachieve thenon-HDLcholes-terolgoal.Thereare2approachestodrugtherapy. First, the non-HDL cholesterolgoal can be achieved by intensifyingtherapywithanLDL-loweringdrug;sec-ond, nicotinic acid or fibrate can beadded, if used with appropriate caution,toachieve thenon-HDLcholesterolgoalby further lowering VLDL cholesterol.In rare cases in which triglycerides arevery high ($500 mg/dL), the initial aimof therapy is to prevent acute pancreati-tis through triglyceride lowering. Thisapproach requires very low-fat diets(#15% of calorie intake), weight reduc-tion, increasedphysicalactivity,andusu-allya triglyceride-loweringdrug(fibrateor nicotinic acid). Only after triglycer-idelevelshavebeenloweredto,500mg/dL should attention turn to LDL lower-ing to reduce risk for CHD.

Low HDL Cholesterol. Low HDL cho-lesterol is a strong independent predic-tor of CHD. In ATP III, low HDL cho-lesterol is defined categorically as a level,40 mg/dL, a change from the level of,35 mg/dL in ATP II. In the presentguidelines, low HDL cholesterol bothmodifies the goal for LDL-loweringtherapy and is used as a risk factor toestimate 10-year risk for CHD.

Low HDL cholesterol levels have sev-eral causes, many of which are associ-ated with insulin resistance, ie, elevatedtriglycerides, overweight and obesity,physical inactivity, and type 2 diabe-tes. Other causes are cigarette smok-ing, very high carbohydrate intakes(.60% of calories), and certain drugs(eg, b-blockers, anabolic steroids, pro-gestational agents).

ATPIIIdoesnotspecifyagoal forHDLraising.Althoughclinical trial resultssug-

gest that raisingHDLwill reducerisk, theevidence is insufficient to specify a goalof therapy.Furthermore, currentlyavail-abledrugsdonotrobustlyraiseHDLcho-lesterol. Nonetheless, a low HDL shouldreceive clinical attention and manage-ment according to the followingsequence. In all persons with low HDLcholesterol, theprimary targetof therapyis LDL cholesterol; ATP III guidelinesshould be followed to achieve the LDLcholesterol goal. Second, after the LDLgoal has been reached, emphasis shiftstoweight reductionand increasedphysi-cal activity (when the metabolic syn-drome is present). When a low HDLcholesterol is associated with high tri-glycerides (200-499 mg/dL), secondarypriority goes to achieving the non-HDLcholesterolgoal, asoutlinedearlier.Also,if triglycerides are ,200 mg/dL (iso-lated low HDL cholesterol), drugs forHDL raising (fibrates or nicotinic acid)can be considered; however, treatmentfor isolated low HDL is mostly reservedfor persons with CHD and CHD riskequivalents.

Diabetic Dyslipidemia. This disorderis essentially atherogenic dyslipidemia inpersons with type 2 diabetes. Althoughelevated triglycerides, low HDL choles-terol, or both are common in personswith diabetes, clinical trial results sup-port the identification of LDL choles-terol as the primary target of therapy, asit is in those without diabetes. Since dia-betes is designated a CHD risk equiva-lent in ATP III, the LDL cholesterol goalof therapy for most persons with diabe-tes will be ,100 mg/dL. Furthermore,when LDL cholesterol is $130 mg/dL,most persons with diabetes will requireinitiation of LDL-lowering drugs simul-taneously with TLC to achieve the LDLgoal. When LDL cholesterol levels are inthe range of 100-129 mg/dL at baselineor on treatment, several therapeutic op-tions are available: increasing intensityof LDL-lowering therapy, adding a drugto modify atherogenic dyslipidemia (fi-brate or nicotinic acid), or intensifyingcontrol of other risk factors including hy-perglycemia. When triglyceride levels are$200 mg/dL, non-HDL cholesterol be-comes a secondary target of cholesterol-

lowering therapy. Several ongoing clini-cal trials (eg, Antihypertensive and LipidLowering Heart Attack Trial [ALLHAT])will better quantify the magnitude of thebenefit of LDL-lowering treatment inolder individuals with diabetes. In olderpersons ($65 years) with diabetes butnoadditionalCHDrisk factorsother thanage, clinical judgment is required for howintensively to apply these guidelines.A variety of factors, including concomi-tant illnesses, general health status, andsocial issues, may influence treatmentdecisions and may suggest a more con-servative approach.

Special Considerations forDifferent Population GroupsMiddle-Aged Men (35-65 Years). In gen-eral,menhaveahigher risk forCHDthando women. Middle-aged men in particu-lar have a high prevalence of the majorrisk factors and are predisposed to ab-dominal obesity and the metabolic syn-drome. A sizable fraction of all CHD inmen occurs in middle age. Thus, manymiddle-aged men carry a relatively highrisk for CHD, and for those who do, in-tensive LDL-lowering therapy is needed.

Women Aged 45-75 Years. In women,onset of CHD generally is delayed bysome 10 to 15 years compared with thatin men; thus, most CHD in women oc-curs after age 65 years. All risk factorscontribute to CHD in women, and mostpremature CHD in women (,65 years)occurs in those with multiple risk fac-tors and the metabolic syndrome. De-spite the previous belief that the sexdifference in risk for CHD reflects a pro-tective effect of estrogen in women, re-cent secondary and primary preven-tion trials cast doubt on the use ofhormone replacement therapy to re-duce CHD risk in postmenopausalwomen. In contrast, the favorable ef-fects of statin therapy in women in clini-cal trials make a cholesterol-loweringdrug preferable to hormone replace-ment therapy for CHD risk reduction.Women should be treated similarly tomen for secondary prevention. For pri-mary prevention, ATP IIIs general ap-proach is similarly applicable forwomen and men. However, the later on-



set of CHD for women in general shouldbe factored into clinical decisions aboutuse of cholesterol-lowering drugs.

Older Adults (Men 65 Years andWomen 75 Years). Overall, most newCHD events and most coronary deathsoccur in older persons ($65 years). Ahigh level of LDL cholesterol and lowHDL cholesterol still carry predictivepower for the development of CHD inolder persons. Nevertheless, the find-ing of advanced subclinical atheroscle-rosis by noninvasive testing can be help-ful for confirming the presence of highrisk in older persons. Secondary pre-vention trials with statins have in-cluded a sizable number of older per-sons, mostly in the age range of 65 to75 years. In these trials, older personsshowed significant risk reduction withstatin therapy. Thus, no hard-and-fastage restrictions appear necessary whenselecting persons with established CHDfor LDL-lowering therapy. For pri-

mary prevention, TLC is the first lineof therapy for older persons. How-ever, LDL-lowering drugs can also beconsidered when older persons are athigher risk because of multiple risk fac-tors or advanced subclinical athero-sclerosis.

Younger Adults (Men 20-35 Years;Women 20-45 Years). In this age group,CHD is rare except in those with se-vere risk factors, eg, familial hypercho-lesterolemia, heavy cigarette smoking,or diabetes. Even though clinical CHDis relatively rare in young adults, coro-nary atherosclerosis in its early stagesmay progress rapidly. The rate of devel-opment of coronary atherosclerosis ear-lier in life correlates with the major riskfactors. In particular, long-term pro-spective studies reveal that elevated se-rum cholesterol detected in young adult-hood predicts a higher rate of prematureCHD in middle age. Thus, risk factoridentification in young adults is an im-portant aim for long-term prevention.The combination of early detection andearly intervention on elevated LDL cho-lesterol with life-habit changes offers theopportunity for delaying or preventingonset of CHD later in life. For youngadults with LDL cholesterol levels of$130 mg/dL, TLC should be institutedand emphasized. Particular attentionshould be given to young men whosmoke and have a high LDL choles-terol (160-189 mg/dL); they may be can-didates for LDL-lowering drugs. Whenyoung adults have very high LDL cho-lesterol levels ($190 mg/dL), drugtherapy should be considered, as in otheradults. Those with severe genetic formsof hypercholesterolemia may requireLDL-lowering drugs in combination (eg,statin+bile acid sequestrant).

Racial and Ethnic Groups. AfricanAmericans have the highest overallCHD mortality rate and the highest out-of-hospital coronary death rates of anyethnic group in the United States, par-ticularly at younger ages. Although thereasons for the excess CHD mortalityamong African Americans have notbeen fully elucidated, it can be ac-counted for, at least in part, by the highprevalence of coronary risk factors. Hy-

pertension, left ventricular hypertro-phy, diabetes mellitus, cigarette smok-ing, obesity, physical inactivity, andmultiple CHD risk factors all occurmore frequently in African Americansthan in whites. Other ethnic groups andminority populations in the UnitedStates include Hispanics, Native Ameri-cans, Asian and Pacific Islanders, andSouth Asians. Although limited datasuggest that racial and ethnic groupsvary somewhat in baseline risk forCHD, this evidence did not appearsufficient to lead the ATP III panel tomodify general recommendationsfor cholesterol management in thesepopulations.

ADHERENCE TOLDL-LOWERING THERAPYAdherence to the ATP III guidelines byboth patients and providers is a key toapproximating the magnitude of thebenefits demonstrated in clinical tri-als of cholesterol lowering. Adher-ence issues have to be addressed to at-tain the highest possible levels of CHDrisk reduction. Thus, ATP III recom-mends the use of state-of-the-art mul-tidisciplinary methods targeting the pa-tient, clinicians, and health deliverysystems to achieve the full populationeffectiveness of the guidelines forprimary and secondary prevention(TABLE 10).

Table 10. Interventions to ImproveAdherence

Focus on the Patient

Simplify medication regimens Provide explicit patient instruction and use good

counseling techniques to teach the patient howto follow the prescribed treatment

Encourage the use of prompts to help patientsremember treatment regimens

Use systems to reinforce adherence andmaintain contact with the patient

Encourage the support of family and friends Reinforce and reward adherence Increase visits for patients unable to achieve

treatment goal Increase the convenience and access to care Involve patients in their care through

self-monitoring

Focus on the Physician and Medical Office

Teach physicians to implement lipid treatmentguidelines

Use reminders to prompt physicians to attendto lipid management

Identify a patient advocate in the office to helpdeliver or prompt care

Use patients to prompt preventive care Develop a standardized treatment plan to

structure care Use feedback from past performance to foster

change in future care Remind patients of appointments and follow up

missed appointments

Focus on the Health Delivery System

Provide lipid management through a lipid clinic Utilize case management by nurses Deploy telemedicine Utilize the collaborative care of pharmacists Execute critical care pathways in hospitals

National Cholesterol EducationProgram Expert Panel on Detection,Evaluation, and Treatment of HighBlood Cholesterol in Adults (AdultTreatment Panel III)Members: Scott M. Grundy, MD, PhD (Chairof the panel), Diane Becker, RN, MPH, ScD,Luther T. Clark, MD, Richard S. Cooper, MD,Margo A. Denke, MD, Wm. James Howard, MD,Donald B. Hunninghake, MD, D. Roger Illing-worth, MD, PhD, Russell V. Luepker, MD, MS,Patrick McBride, MD, MPH, James M. McK-enney, PharmD, Richard C. Pasternak, MD, NeilJ. Stone, MD, Linda Van Horn, PhD, RD

Ex-officio Members: H. Bryan Brewer, Jr, MD,James I. Cleeman, MD (Executive Director of thepanel), Nancy D. Ernst, PhD, RD, David Gor-don, MD, PhD, Daniel Levy, MD, Basil Rifkind,MD, Jacques E. Rossouw, MD, Peter Savage, MD

Consultants: Steven M. Haffner, MD, DavidG. Orloff, MD, Michael A. Proschan, PhD, J. San-ford Schwartz, MD, Christopher T. Sempos, PhD

Staff: Susan T. Shero, RN, MS, Elaine Z.Murray



FinancialDisclosure: DrGrundyhas receivedhonoraria fromMerck, Pfizer, Sankyo, Bayer, and Bristol-Myers Squibb. DrHunninghakehascurrentgrants fromMerck,Pfizer,KosPhar-maceuticals, Schering Plough, Wyeth Ayerst, Sankyo, Bayer,AstraZeneca, Bristol-Myers Squibb, and G. D. Searle; he hasalso received consulting honoraria from Merck, Pfizer, KosPharmaceuticals,Sankyo,AstraZeneca,andBayer.DrMcBridehas received grants and/or research support from Pfizer,Merck, Parke-Davis, and AstraZeneca; has served as a con-sultant for Kos Pharmaceuticals, Abbott, and Merck; and hasreceived honoraria from Abbott, Bristol-Myers Squibb, Nov-artis, Merck, Kos Pharmaceuticals, Parke-Davis, Pfizer, andDuPont. Dr Pasternak has served as a consultant for andreceived honoraria from Merck, Pfizer, and Kos Pharma-ceuticals, and has received grants from Merck and Pfizer.Dr Stone has served as a consultant and/or received hono-raria for lectures from Abbott, Bayer, Bristol-Myers Squibb,Kos Pharmaceuticals, Merck, Novartis, Parke-Davis/Pfizer,andSankyo.DrSchwartzhasservedasaconsultant forand/orconducted research funded by Bristol-Myers Squibb,AstraZeneca, Merck, Johnson & Johnson-Merck, and Pfizer.Executive Committee Liaison to the Panel: Stephen Havas,MD, MPH, MSReviewers of the Full Report of ATP III: Eugene Braun-wald, MD, W. Virgil Brown, MD, Alan Chait, MD, James E.Dalen, MD, Valentin Fuster, MD, PhD, Henry N. Ginsberg,MD, Antonio M. Gotto, MD, DPhil, Ronald M. Krauss, MD,John C. LaRosa, MD, Thomas H. Lee, Jr, MD, Linda Mey-ers, PhD, Michael Newman, MD, Thomas Pearson, MD, PhD,Daniel J. Rader, MD, Frank M. Sacks, MD, Ernst J. Schaefer,MD, Sheldon G. Sheps, MD, Lynn A. Smaha, MD, PhD, Sid-ney C. Smith, Jr, MD, Jeremiah Stamler, MD, Daniel Stein-berg, MD, PhD, Nanette K. Wenger, MDNationalCholesterolEducationProgramCoordinatingCom-mittee: The Third Report of the Expert Panel on Detec-tion, Evaluation, and Treatment of High Blood Cholesterolin Adults was approved by the National Cholesterol Edu-cation Program Coordinating Committee, which comprisesthe following organizational representatives:

MemberOrganizations: NationalHeart, Lung,andBloodInstitute: Claude Lenfant, MD (Chair), James I. Cleeman,MD (Coordinator); American Academy of Family Physi-cians:TheodoreG.Ganiats,MD;AmericanAcademyof Insur-ance Medicine: Gary Graham, MD; American Academy ofPediatrics: Ronald E. Kleinman, MD; American Associationof Occupational Health Nurses: Pamela Hixon, BSN, RN,COHN-S; American College of Cardiology: Richard C. Pas-ternak, MD; American College of Chest Physicians: GeraldT. Gau, MD, American College of Nutrition: Harry Preuss,MD; American College of Obstetricians and Gynecolo-gists: Thomas C. Peng, MD; American College of Occupa-tional and Environmental Medicine: Ruth Ann Jordan, MD;American College of Preventive Medicine: Lewis H. Kuller,MD, DrPH; American Diabetes Association, Inc: Alan J. Gar-ber, MD, PhD; American Dietetic Association: Linda VanHorn, PhD, RD; American Heart Association: Scott M.Grundy, MD, PhD; American Hospital Association: SandraCornett, RN, PhD; American Medical Association: Yank D.Coble, Jr, MD; American Nurses Association: to be named;American Osteopathic Association: Michael Clearfield, DO;American Pharmaceutical Association: James M. McKen-ney, PharmD; American Public Health Association: Ste-phen Havas, MD, MPH, MS; American Red Cross: DonaldVardell, MS; Association of Black Cardiologists: Karol Wat-son, MD, PhD; Association of State and Territorial HealthOfficials: Joanne Mitten, MHE; Citizens for Public Actionon Blood Pressure and Cholesterol, Inc: Gerald J. Wilson,MA, MBA; National Black Nurses Association, Inc: LindaBurnes-Bolton, DrPH, RN, MSN; National Medical Asso-ciation: Luther T. Clark, MD; Society for Nutrition Educa-tion: Darlene Lansing, MPH, RD; Society for Public HealthEducation: Donald O. Fedder, DrPH, MPH.

Associate Member Organization: American Associa-tion of Office Nurses: Joyce Logan.

Federal Agencies: NHLBI Ad Hoc Committee on Minor-ity Populations: Yvonne L. Bronner, ScD, RD, LD; Agencyfor Healthcare Research and Quality: Francis D. Chesley,Jr, MD; Centers for Disease Control and Prevention: WayneGiles, MD, MPH; Coordinating Committee for the Com-munity Demonstration Studies: Thomas M. Lasater, PhD;Department of Agriculture: Alanna Moshfegh, MS, RD;Department of Defense: Col Robert Dana Bradshaw, MD,MPH;FoodandDrugAdministration: ElizabethYetley,PhD;Health Resources and Services Administration: Celia Hayes,MPH, RD; National Cancer Institute: Carolyn Clifford, PhD;National Center for Health Statistics: Clifford Johnson,MPH; Office of Disease Prevention and Health Promo-tion: Elizabeth Castro, PhD; Department of Veterans Affairs:Pamela Steele, MD.

APPENDIX

Shared Features of ATP III and ATP II

Adult Treatment Panel (ATP) III shares a set of core features with ATP II,shown in Table A.

Table A. Shared Features of ATP III and ATP II*

Continued identification of LDL cholesterol lowering as the primary goal of therapy Consideration of high LDL cholesterol ($160 mg/dL) as a potential target for LDL-lowering

drug therapy, specifically as follows:For persons with multiple risk factors whose LDL levels are high ($160 mg/dL) after

dietary therapy, consideration of drug therapy is recommendedFor persons with 0-1 risk factor, consideration of drug therapy (after dietary therapy) is

optional for LDL 160-189 mg/dL and recommended for LDL $190 mg/dL Emphasis on intensive LDL-lowering therapy in persons with established CHD Identification of 3 categories of risk for different LDL goals and different intensities of

LDL-lowering therapy:CHD and CHD risk equivalents (other forms of clinical atherosclerotic disease)Multiple (2+) risk factors0-1 risk factor

Identification of subpopulations, besides middle-aged men, for detection of high LDLcholesterol (and other lipid risk factors) and for clinical intervention. These include:

Young adultsPostmenopausal womenOlder persons

Emphasis on weight loss and physical activity to enhance risk reduction in persons withelevated LDL cholesterol

*ATP indicates Adult Treatment Panel; LDL, low-density lipoprotein; and CHD, coronary heart disease.A CHD risk equivalent is a condition that carries an absolute risk for developing new CHD equal to the risk for

having recurrent CHD events in persons with established CHD.Risk factors that continue to modify the LDL goal include cigarette smoking, hypertension, low HDL choles-

terol, family history of premature CHD, age (male $45 years and female $55 years), and diabetes (in ATPIII diabetes is regarded as a CHD risk equivalent).

Estimating 10-Year Risk for Men and WomenRisk assessment for determining the 10-year risk for developing CHD iscarried out using Framingham risk scoring (Table B1 for men and TableB2 for women). The risk factors included in the Framingham calculationof 10-year risk are age, total cholesterol, HDL cholesterol, systolic bloodpressure, treatment for hypertension, and cigarette smoking. The first stepis to calculate the number of points for each risk factor. For initial assess-ment, values for total cholesterol and HDL cholesterol are required. Be-cause of a larger database, Framingham estimates are more robust for to-tal cholesterol than for LDL cholesterol. Note, however, that the LDLcholesterol level remains the primary target of therapy. Total cholesteroland HDL cholesterol values should be the average of at least 2 measure-ments obtained from lipoprotein analysis. The blood pressure value usedis that obtained at the time of assessment, regardless of whether the per-son is on antihypertensive therapy. However, if the person is on antihy-pertensive treatment, an extra point is added beyond points for the bloodpressure reading because treated hypertension carries residual risk (TablesB1 and B2). The average of several blood pressure measurements, as rec-ommended by the Joint National Committee (JNC), is needed for an ac-curate measure of baseline blood pressure. The designation smoker meansany cigarette smoking in the past month. The total risk score sums thepoints for each risk factor. The 10-year risk for myocardial infarction andcoronary death (hard CHD) is estimated from total points, and the personis categorized according to absolute 10-year risk as indicated above (seeTable 5).



Table B1. Estimate of 10-Year Risk for Men(Framingham Point Scores)

Age, y Points

20-34 935-39 440-44 045-49 350-54 655-59 860-64 1065-69 1170-74 1275-79 13

TotalCholesterol,

mg/dL

Points

Age20-39 y

Age40-49 y

Age50-59 y

Age60-69 y

Age70-79 y

,160 0 0 0 0 0160-199 4 3 2 1 0200-239 7 5 3 1 0240-279 9 6 4 2 1

$280 11 8 5 3 1

Points

Age20-39 y

Age40-49 y

Age50-59 y

Age60-69 y

Age70-79 y

Nonsmoker 0 0 0 0 0Smoker 8 5 3 1 1

HDL, mg/dL Points

$60 150-59 040-49 1,40 2

Systolic BP, mm Hg If Untreated If Treated

,120 0 0120-129 0 1130-139 1 2140-159 1 2

$160 2 3

Table B2. Estimate of 10-Year Risk for Women(Framingham Point Scores)

Point Total 10-Year Risk, %

,0 ,10 11 12 13 14 15 26 27 38 49 5

10 611 812 1013 1214 1615 2016 25

$17 $30

Age, y Points

20-34 735-39 340-44 045-49 350-54 655-59 860-64 1065-69 1270-74 1475-79 16

TotalCholesterol,

mg/dL

Points

Age20-39 y

Age40-49 y

Age50-59 y

Age60-69 y

Age70-79 y

,160 0 0 0 0 0160-199 4 3 2 1 1200-239 8 6 4 2 1240-279 11 8 5 3 2

$280 13 10 7 4 2

Points

Age20-39 y

Age40-49 y

Age50-59 y

Age60-69 y

Age70-79 y

Nonsmoker 0 0 0 0 0Smoker 9 7 4 2 1

HDL, mg/dL Points

$60 150-59 040-49 1,40 2

Systolic BP, mm Hg If Untreated If Treated

,120 0 0120-129 1 3130-139 2 4140-159 3 5

$160 4 6

Point Total 10-Year Risk, %

,9 ,19 1

10 111 112 113 214 215 316 417 518 619 820 1121 1422 1723 2224 27

$25 $30



atp iii ncep

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