Some Thoughts on the Adult Treatment Panel III Report

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.