Low-Density-Lipoprotein Cholesterol Goals for Patients With Coronary Disease

The National Cholesterol Education Panel Adult Treatment III guidelines,1 which were released earlier this year, recommend that the number of Americans who should be treated with cholesterol-lowering drugs increase from 13 million to 36 million. This action is justified because coronary disease remains the leading cause of death in this country and because of the overwhelming evidence from clinical trials that statins reduce coronary events and are safe. Many of the additional individuals for whom drug treatment is now recommended have diabetes or other factors that increase their risk to the level of patients with documented atherosclerosis. Calibrating the intensity of treatment to the level of risk is a rational and efficient approach.See p 2660 One feature of the guidelines that has not changed is the target of LDL levels <100 mg/dL for patients with documented atherosclerosis. This cut point was selected before the publication of any of the major statin trials, and no compelling data has emerged since then to indicate that it should be adjusted either upward or downward. The guidelines also continue to recommend that diet and other lifestyle interventions be used to attain this goal and that drugs also be used when the LDL cholesterol level exceeds 130 mg/dL.The guidelines leave to the discretion of the physician whether drug treatment is prescribed for patients whose LDL-cholesterol remains between 100 and 130 mg/dL. In one study of 8500 men with coronary disease, the authors estimated that 37% of their cohort would have LDL-cholesterol values within this range after successful treatment with diet.2 Thus, physicians commonly face the decision of whether or not they should begin a statin or increase the intensity of drug therapy for patients with LDL-cholesterol levels in this range. The article by White et al 3 in the present issue …