Eligibility for Lipid-Lowering Drug Therapy in Primary Prevention

Abstract

In May 2001, the Adult Treatment Panel III (ATP III) of the National Cholesterol Education Program issued revised guidelines for diagnosing and treating high blood cholesterol.1 These guidelines represent a major advance in risk assessment. They were preceded by the ATP I guidelines (1988), which focused on primary prevention of coronary heart disease (CHD), and by the ATP II guidelines (1993),2 which discussed primary and secondary prevention. In the ATP II and ATP III guidelines, low-density lipoprotein cholesterol (LDL-C) is the primary target of risk-reduction therapy. See p 152 The ATP II recommendations were based on epidemiological, preclinical, and incomplete clinical trial evidence. Within a few years after their publication, the results of 5 large-scale trials of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (ie, “statins”) were reported. Two of these (West of Scotland Coronary Prevention Study [WOSCOPS] and Air Force/Texas Coronary Atherosclerosis Prevention Study [AFCAPS/TexCAPS]) were primary-prevention trials.3,4 The remaining 3 focused on secondary prevention.5-7 Based on these epic trials and other laboratory, epidemiological, and clinical evidence, the ATP III guidelines were developed (Tables 1 and 2⇓). View this table: Table 1103484. ATP III Guidelines: New Features View this table: Table 2103484. ATP III Guidelines: Global Risk Assessment The major statin trials and resulting meta-analyses provided a firm foundation for a truly evidence-based approach to guideline revision. Involving 5 different populations with widely varying absolute risk levels and using 3 different statins (simvastatin, pravastatin, lovastatin), they produced remarkably consistent reductions of 24% to 37% in relative risk for major CHD events. In WOSCOPS, 6595 men with moderate hypercholesterolemia (LDL-C=192 mg/dL±SD) received pravastatin 40 mg/day for up to 4.9 years. Results indicated a 31% relative decrease in major CHD events, with a 26% reduction in LDL-C levels. AFCAPS/TexCAPS evaluated lovastatin 20 to 40 mg/day for up to 5.2 years in 6605 generally healthy men and women with …