Past, present, and future standards for management of dyslipidemia

Evolution of the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) guidelines for lipid lowering reflects a movement toward global risk assessment, including improved identification of risk in individuals without established coronary heart disease (CHD), and toward more aggressive lipid-lowering targets to reduce CHD risk. The current guidelines, for example, identify a segment of the population without established CHD as being at high risk on the basis of criteria that indicate CHD risk equivalency, recommend a low-density lipoprotein cholesterol (LDL-C) plasma level <100 mg/dL as optimal in all individuals, and establish the metabolic syndrome as a secondary target for therapeutic intervention. Many questions remain for future guidelines to address: To what extent should plasma levels of LDL-C be lowered by therapy to afford optimal risk reduction? Can risk assessment be improved, e.g., by using novel risk measures (such as high-sensitivity C-reactive protein) to indicate patients at higher risk who may benefit from more aggressive interventions? Should the metabolic syndrome be considered a high-risk state warranting aggressive intervention irrespective of risk categorization using current scoring methods? Guidelines for lipid management represent a synthesis of constantly emerging and evolving data: ongoing efforts to improve understanding of the relation between dyslipidemia and cardiovascular disease, to increase knowledge of and ability to measure other CHD risk factors, and to improve therapeutic practices and options will be reflected in future guidelines.