There appears to be little doubt that lowering serum cholesterol for reduction of risk for coronary artery disease (CAD) events in patients with established CAD is cost-effective and can decrease the rate of CAD events, stabilize atherosclerotic plaque progression, and reduce CAD mortality and all-cause mortality. Meta-analysis of clinical trials conducted in patients with CAD has shown a 26% reduction in CAD events and a 9% reduction in total mortality. It was generalized from the results of nine major, recent angiographically monitored clinical trials that an improvement in obstruction was seen in 8% of control patients and 25% of treated patients. In the recently released report of the second Adult Treatment Panel (ATP II) of the U.S. National Cholesterol Education Program, atherosclerotic disease status joins low-density lipoprotein cholesterol (LDL-C) level as central to the diagnosis and treatment algorithm. The ATP II evaluation process is divided into two categories according to whether atherosclerotic disease is present, and a lower LDL-C target level - 100 mg/dL (2.6 mmol/L) - is set for secondary prevention. Initial therapy when LDL-C is ≥100 mg/dL in a patient with atherosclerotic disease is the Step Two Diet, weight control, exercise, and control of other risk factors. Drug therapy may be considered after a relatively short trial of hygienic therapy if LDL-C remains ≥130 mg/dL (3.4 mmol/L). Other, selected aspects of heart disease for general consideration in assessing CAD risk are family history and the presence of left ventricular hypertrophy (LVH). Family history of premature CAD is included in the ATP II algorithm, with different age considerations by gender added. Although LVH is not part of ATP II risk assessment, its presence as defined by echocardiography increases CAD risk six- to eightfold in both men and women.
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