The updated guidelines of the US National Cholesterol Education Program (NCEP) suggest that people at risk for myocardial infarction and stroke would benefit from more intensive cholesterol-lowering therapies, according to the update published in the July 13th issue of Circulation. The updated recommendations are endorsed by the National Heart, Lung and Blood Institute (National Institutes of Health); the American Heart Association; and the American College of Cardiology.

Dr. Scott M. Grundy said the new guidelines are based largely on results from five major clinical trials involving statins. These results made it possible to revise the 2001 guidelines issued by the Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III), for which Dr. Grundy served as chairman.

The Program identifies three categories of risk based on a person’s likelihood to develop cardiovascular disease in the near future: high risk, moderately high risk, and lower to moderate risk. High-risk individuals are those who have already had a myocardial infarction, angina, previous angioplasty or bypass surgery, peripheral arterial disease, diabetes, or a mix of other risk factors that raise the risk for myocardial infarction in the next 10 years by more than 20 percent.

For high-risk patients, the guidelines issued in 2001 called for doctors to prescribe cholesterol-lowering drugs along with dietary therapy as necessary to reduce low-density lipoprotein (LDL) cholesterol levels to less than 100 milligrams per deciliter. Recent clinical trials allowed the panel to identify a subgroup of high-risk patients who can be considered at very high risk and who may benefit from even more intensive lowering of low-density lipoprotein cholesterol. For very high-risk persons, the new guidelines give physicians the option of reducing low-density cholesterol to less than 70 mg/dL.

Patients are considered at very high risk if they already have cardiovascular disease plus diabetes, are persistent smokers, have poorly controlled hypertension or metabolic syndrome, or a history of recent myocardial infarction.

For people who are at moderately high risk - those who have two or more risk factors for coronary heart disease and have a 10 percent to 20 percent chance of having a myocardial infarction in the next 10 years - ATP III recommended reducing LDL cholesterol to less than 130 mg/dL. Recent clinical trials, however, strongly suggest that moderately high-risk people will receive additional benefit if their LDL levels are reduced to less than 100 mg/dL.

Recent clinical trials also provide strong evidence that cholesterol-lowering therapy is effective in reducing cardiovascular disease in patients with diabetes as well as older persons who are at risk. Guidelines for people with lower to moderate risk for cardiovascular disease were unchanged.

“The report also emphasizes the importance of making lifestyle changes that help with cholesterol management, including eating a low-saturated fat, low-cholesterol diet; increasing fiber intake; losing weight, and exercising regularly,” Dr. Grundy said. “These should always be employed when patients are given cholesterol-lowering drugs.”

The five clinical trials reviewed by the NCEP working group were the Heart Protection Study (HPS), the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER), the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial-Lipid Lowering Trial (ALLHAT-LLT), the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm (ASCOT-LLA), and the Pravastatin or Atorvastatin Evaluation and Infection-Thrombolysis in Myocardial Infarction (PROVE IT-TIMI 22).