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Heart Protection Study Implications for Lipid Management Guidelines and Practices

While Heart Protection Study (HPS) findings support aggressive lowering of low-density lipoprotein (LDL) cholesterol levels and suggest optimal levels well below current recommendations, failure to achieve current goals for LDL cholesterol is common.

In a recently published article, Christie M. Ballantyne, M.D., of Baylor College of Medicine in Houston, Texas, United States, provided a review of lipid management guidelines, including history and current challenges to guidelines and clinical practice due to HPS results.

The National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) I published the initial lipid management guidelines, which focused on lowering LDL cholesterol as a therapeutic guide. Later, ATP II guidelines shifted to coronary artery disease (CAD) risk assessment, established a target LDL cholesterol level of <100 mg/dL for CAD patients, and introduced the use of statins, currently the first line treatment.

ATP III guidelines shifted to more global risk assessment, provided a reduction in LDL cholesterol threshold in high-risk patients for treatment initiation, established non-high-density lipoprotein (non-HDL) cholesterol as a secondary therapeutic target, and introduced the category of CAD risk equivalent which provided more individuals with an aggressive LDL cholesterol target level of <100 mg/dL

However, HPS findings demonstrated that a reduction of major vascular events extended even to CAD patients with initial LDL cholesterol levels <100 mg/dL using simvastatin 40 mg, suggesting that the optimal LDL cholesterol level is below target levels established in current guidelines.

"Achievement of even the current LDL cholesterol goals in clinical practice requires more intensive lipid-modifying therapy than that currently practiced," Dr. Ballantyne notes.

Evidence suggests that greater effectivity improves statin therapy benefit. New statins offer greater beneficial changes in LDL cholesterol and other lipid risk markers. Research indicates that rosuvastatin is more effective than other statins in reducing LDL cholesterol, enabling more patients to achieve LDL cholesterol goals.

Am J Cardiol 2003 Aug 21;92:4B:3K-9K. "Current and future aims of lipid-lowering therapy: changing paradigms and lessons from the heart protection study on standards of efficacy and safety"

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