Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines

Abstract

In 2001, the Adult Treatment Panel III of the National Cholesterol Education Program issued recommendations, which were updated in 2004 to reflect knowledge from five major clinical trials completed after 2001. This review discusses the results of key clinical trials released in 2005 and their potential impact on the guidelines. Three major clinical trials, one subgroup analysis, and one meta-analysis were published in 2005 that can potentially affect the existing guidelines. The Treating to New Targets and the Incremental Decrease in End Points Through Aggressive Lipid Lowering trials demonstrated the incremental benefit of more aggressive low-density cholesterol lowering in stable coronary heart disease. The Cholesterol Treatment Trialists' Collaboration meta-analysis of statin trials supported the importance of low-density lipoprotein cholesterol reduction, irrespective of initial lipid profile, in reducing cardiovascular events. A subgroup analysis of the Anglo-Scandinavian Cardiac Outcomes Trial - Lipid-Lowering Arm demonstrated statin benefits in diabetes, whereas the Fenofibrate Intervention and Event Lowering in Diabetes study failed to show overall treatment benefits with a fibrate in diabetes. Lowering of low-density lipoprotein cholesterol remains central in reducing cardiovascular risk; however, the recent trials support a target of less than 2.0 mmol/l (<80 mg/dl), rather than the less than 1.8 mmol/l (70 mg/dl) suggested by the 2004 update, for all high-risk patients and not, as recommended previously, just for those with additional factors. For individuals with diabetes, recent data support the use of statin therapy, even in those at less than high risk. First-line therapy should remain statins and not fibrates.