Guidelines and global risk: A U.S. perspective

Several studies have shown that coronary heart disease is poorly controlled in the U.S.A. In particular, in a significant proportion of patients, cholesterol levels are not being measured, and individuals who have been prescribed lipid-lowering medication usually fail to achieve recommended targets. The National Cholesterol Education Program has recently published the recommendations of its third Adult Treatment Panel (ATP III). These guidelines differ from earlier guidelines in several ways. They advocate assessment of global risk in order to determine the type and intensity of treatment employed. Global risk calculation is based on a modified version of the Framingham algorithm, with a point-score system. Although low-density lipoprotein cholesterol continues to be highlighted as the primary target of therapy, ATP III for the first time officially defines the metabolic syndrome and considers it a secondary target for treatment. ATP III also recommends non-high-density lipoprotein cholesterol as a secondary target for patients with high triglyceride levels, because data indicate that hypertriglyceridaemia is an independent risk factor for coronary heart disease. Under these new guidelines, three times as many people will qualify for treatment as compared with previous guidelines, representing a large increase in health care expenditure and important new challenges for clinicians.