The National Cholesterol Education Program Adult Treatment Panel (NCEP ATP) III guidelines on the management of hypercholesterolemia1 were published more than a decade ago, with a white paper update in 2004. The ATP IV guidelines, due out soon, will translate for us the advances in science and clinical evidence that, as I see things, should already be changing the way we treat our patients.
In the meantime, I worked with an expert group of physicians to develop a set of actionable recommendations for the ATP update. Following is a 10-point summary of those recommendations, written to specifically address primary care practice. They are, by design, as straightforward as possible to make implementation easier in the clinic.
Recommendation #1: Assess risk more accurately.
• The Framingham Risk Score for hard coronary heart disease (CHD) is the global risk measure in ATP III.
• A powerful tool, but limits inputs (traditional risk factors only), outputs (nonfatal MI and CHD death only), and time span (10 years only)
• Underestimates risk in many patients, particularly women
• Ignores factors like kidney disease and a family history of CHD
• Risk scoring does not include stroke, known to be preventable by statins
• Most adults with first MI were not ATP III candidates for statins
» Two common alternatives (more comprehensive, but still imperfect):
• Both address more comprehensive end-points, including stroke
• Reynolds risk: adds C-reactive protein (CRP) level and parental history of premature MI to Framingham traditional risk factors
• Framingham global cardiovascular disease (CVD) risk: uses lab or clinical inputs; easy estimation using bedside point system; gives “heart age”
• Expect updated risk calculators in the near future
• Providers in a busy primary care clinic may not always calculate a risk score
» The CHD risk equivalent allows a provider to quickly classify risk:
• CHD risk equivalent: ≥20% 10-yr risk of MI or death from CHD
• Diabetes mellitus (DM) is a CHD risk equivalent in ATP III
• We recommend stage ≥2 chronic kidney disease as a CHD risk equivalent
• Other factors modify risk (eg, age, disease duration), so a young patient with newly diagnosed diabetes may be a common exception to the CHD risk equivalent rule
» Lifetime risk is also a quick way to classify risk
• A viable conceptual framework for patients estimated to carry low-to- intermediate 10-yr risk
• High lifetime risk: ≥39% lifetime chance of developing CVD
• Roughly equivalent to reaching age 50 with 1 major risk factor
• Risk scores yield point estimates; in reality, there is a 95% CI around this estimate, which highlights the uncertainty of risk estimation by these tools alone. When more precise risk estimation is needed, consider referral for noninvasive atherosclerosis imaging, such as coronary artery calcium scanning, especially for patients with family histories of CHD or metabolic syndrome.
Recommendation #2: Simplify the starting algorithm.
• Current starting algorithm: Risk assessment → Baseline LDL-C → LDL-C goal
» LDL-C cut-points for lifestyle changes and drugs are different, which is confusing
» Baseline LDL-C is a “middle man”
• However, per ATP III, “When persons with low LDL-C have the same absolute risk (because of other risk factors) as those with high LDL-C, the same absolute benefit is attained for a given mg/dL lowering of LDL-C.”
• Our suggested simplified starting algorithm: Risk assessment → Therapy
» More evidence-based, easier to follow, and in line with ATP III logic above
» Focus on healthy lifestyle is important for all; don’t need LDL-C cut-points
» Low short-term and lifetime-risk patients: focus on AHA ideal CV health
» High short-term risk (CHD risk equivalent): potent statin therapy typically
» Then there are those in the middle (ie, patients with CV risk factors)
» Many high-lifetime risk patients benefit from statin therapy, which should be discussed
• Five Ps to consider when discussing a statin:
• Preference: What does the patient prefer?
• Precision: Need further testing for more precise risk stratification?
• Participation: Is the patient motivated to improve lifestyle habits?
• Potency: What statin potency will likely be required?
• Price: Can the patient afford the drug, and do the benefits likely outweigh the risks?