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Perspectives: some thoughts on the Adult Treatment Panel III report
1Columbia University College of Physicians and Surgeons, New York, NY 10022, USA. CBB1@worldnet.att.net
Insights
The Adult Treatment Panel III (ATP III) cholesterol guidelines need simplification. Current complexity may hinder widespread use and lead to under-treatment, especially for women.
Area of Science:
- Cardiology
- Public Health
Background:
- The National Cholesterol Education Program's Adult Treatment Panel III (ATP III) guidelines focus on low-density lipoprotein (LDL) cholesterol and coronary heart disease (CHD) risk.
- Newer elements include risk quantification, attention to low high-density lipoprotein (HDL) levels, and emphasis on metabolic syndrome.
Framework:
- ATP III guidelines utilize a hybrid risk assessment combining categorical risk factors and the Framingham model.
- This hybrid approach introduces complexity and inconsistencies in treatment recommendations.
Implementation:
- The current treatment algorithm is overly complex, potentially limiting guideline adoption.
- Guidelines may lead to under-treatment of women and inconsistencies in setting therapeutic LDL goals.
Implications:
- Simplification of ATP III guidelines is crucial for wider implementation.
- Recommendations include enhancing treatment for women and providing an "unlocked" risk-assessment tool for transparency.
Abstract:
The guidelines of the Adult Treatment Panel III (ATP III) of the National Cholesterol Education Program are similar to prior recommendations in focusing on elevations of low-density lipoprotein (LDL) cholesterol as the primary target of therapy and in gauging the intensity of therapy to the degree of coronary heart disease risk. New elements in the current guidelines include: quantification of risk, heightened attention to the risk imparted by low high-density lipoprotein levels, utilization of non-high-density lipoprotein cholesterol levels in risk assessment for hypertriglyceridemic individuals, and emphasis on the metabolic syndrome. Nonetheless, the current guidelines are not perfect. The recommended algorithm for treatment is excessively complex; this complexity may keep the guidelines from being widely used. This complexity is generated by a hybrid scheme of risk assessment utilizing both counting of categorical coronary heart disease risk factors and calculation of coronary heart disease using the Framingham model. This hybrid method also results in undesirable inconsistencies in treatment. ATP III explicitly agrees that the therapeutic LDL goal should be determined by the burden of non-LDL risk factors. However, the current guidelines violate this principle by giving the baseline LDL cholesterol level a role in determining the therapeutic LDL goal. Additionally, the ATP III guidelines lead to under-treatment of women. Simplification should be a goal of the next iteration of the guidelines. Specific suggestions are given for simplification of the guidelines and for enhanced treatment of women. Furthermore, it is urged that the risk-assessing spreadsheet be provided in an "unlocked" form so that its details can be inspected.