NCEP Guidelines and Implications for Cerebrovascular Disease
Source: NCEP Expert Panel. JAMA. 2001;285:2486-2497.
The third report on the evaluation and treatment of elevated cholesterol in adults was released in May 2001. The Adult Treatment Panel III (ATPIII) promotes a much more aggressive stance than its predecessors, particularly with regard to statin therapy in patients with only mildly elevated lipids.
As with previous National Cholesterol Education Program (NCEP) reports, the key lipid component for prevention of atherosclerotic disease is the LDL subfraction. This emphasizes the importance of carrying lipid testing beyond total cholesterol alone. As shown in the Table, among patients with coronary artery disease (CAD), LDL cholesterol should be below 100 mg/dL. If this cannot easily be achieved with diet, then lipid-lowering therapy with a statin agent should be implemented. Patients with symptomatic carotid artery disease are also to be placed in this top category.
| Table: NCEP Cholesterol Management Guidelines | |||
| Risk Category | LDL Goal (mg/dL) |
LDL
Level— Lifestyle change needed |
LDL
Level— Drug therapy to be initiated |
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|
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| 1) Coronary artery disease (or 10-year risk > 20%)* |
< 100 | > 100 | > 130; (100-129, optional) |
| 2) > 2 risk factors** (10-year risk < 20%) |
< 130 | > 130 | a) 10-year CAD risk 10-20%; >
130 b) 10-year CAD risk < 10%; > 160 |
| 0-1 risk factors | < 160 | > 160 | > 190; (160-189, optional) |
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| *10-year risk of coronary artery disease is determined using Framingham Point Scores (calculated on the basis of age, sex, blood pressure, tobacco use, and cholesterol levels) | |||
| **Major risk factors are: tobacco use, hypertension, low HDL-cholesterol levels (< 40 mg/dL), family history of premature CAD, and age (men > 45, women > 55) | |||
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In contrast to prior NCEP guidelines, all patients with diabetes mellitus are considered to have a "coronary artery disease risk equivalent," placing them automatically in the top category. The ATPIII also puts increased emphasis on the effects of elevated cholesterol in women and the elderly. While the majority of early data on statin therapy focused on only middle-aged men, recent studies have indicated the benefit of these agents across a wider range of age and gender.
The ATPIII also argues that patients with a distinct "metabolic syndrome" may gain benefits from statin therapy beyond merely lower cholesterol. This syndrome encompasses a spectrum of abdominal obesity, insulin resistance, atherogenic dyslipidemia (elevated triglyceride, small LDL particles, and low HDL cholesterol) as well as prothrombotic or proinflammatory states. Regression of atherosclerosis in these patients may be promoted with statin therapy. Treatment for hyperglycemia and the use of aspirin may be complementary.
Comment by Alan Z. Segal, MD
Perhaps the most striking aspect of the NCEP report is the unfortunate absence of any reference to stroke. Indeed, the NCEP panel does not include a neurologist and the Member Organization list does not include the American Stroke Association (ASA) or National Stroke Association (NSA).
This leaves neurologists who treat patients with stroke wondering: where does this leave me? If stroke is a vascular disease, can the recommendations as made here for heart disease be followed in parallel? How should prior stroke be factored in among other markers of atherosclerotic disease?
Most information regarding the use of statin therapy for patients with stroke derives from the cardiac literature (patients with CAD). Specific data regarding stroke patients are lacking. Certain forms of stroke, such as those caused by atrial fibrillation or cardiac embolism, may not bear a relation to cholesterol levels. The risk of other forms of stroke such as intracerebral hemorrhage may actually be magnified by low cholesterol.
Stroke is, nevertheless, a vascular disease. For this reason, neurologists should err on the side of caution. Lowering of LDL cholesterol to Category I goals (< 100 mg/dL) or at least Category IIa (< 130 mg/dL) is recommended until more disease-specific data are available.
Dr. Segal is Assistant Professor, Department of Neurology, Weill-Cornell Medical College, Attending Neurologist, New York Presbyterian Hospital, New York, NY.
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