Clinical goals and performance measures for cholesterol management in secondary prevention of coronary heart disease.

Guidelines from the National Cholesterol Education Program (NCEP) recommend reduction of low-density lipoprotein cholesterol (LDL-C) to 100 mg/dL (2.59 mmol/L) or less in patients with established coronary heart disease (CHD). However, the National Committee for Quality Assurance (NCQA) is implementing a new performance measure as part of the Health Plan Employer and Data Information Set (HEDIS) that appears to endorse a different target. The new HEDIS measure will require managed care organizations seeking NCQA accreditation to measure and report the percentage of patients who have had major CHD events who achieve LDL-C levels less than 130 mg/dL (3.36 mmol/L) between 60 and 365 days after discharge. These different LDL-C thresholds emphasize the difference between a clinical goal for the management of individual patients (< or =100 mg/dL) and a performance measure used to evaluate the care of a population of patients (<130 mg/dL). This article discusses the rationale for each threshold and explains the use of 2 different thresholds for these 2 purposes. Both the NCQA and NCEP expect that the new HEDIS measure will encourage managed care organizations to develop systems that improve secondary prevention of CHD.

Cholesterol lowering in the elderly population. Coordinating Committee of the National Cholesterol Education Program.

The incidence of coronary heart disease (CHD) peaks in the elderly population. In secondary and primary prevention trials, cholesterol-lowering therapy reduces risk for CHD in both older and younger participants. This benefit, therefore, can be extended to the elderly.

Detection and evaluation of dyslipoproteinemia.

The National Cholesterol Education Program Adult Treatment Panel II guidelines recommend that all adults 20 years of age and older undergo testing to detect dyslipoproteinemia. Clinical trials have proven conclusively that lowering levels of low-density lipoprotein (LDL) cholesterol reduces coronary heart disease (CHD) incidence and mortality and total mortality in patients with and without CHD. There is persuasive scientific evidence to include young adults, women, and the elderly in the recommendation for cholesterol management. In adult without CHD, testing can begin with measurement of total cholesterol (TC) and high-density lipoprotein (HDL) cholesterol in the nonfasting state, and the results can then be used to determine which individuals require a fasting lipoprotein analysis (total cholesterol, HDL, triglycerides, and estimation of LDL); patients with known CHD should begin with lipoprotein analysis. The level of LDL cholesterol and the presence or absence of other CHD risk factors determine the need for cholesterol-lowering therapy. Patients with known CHD are at highest risk for a CHD event and have the lowest LDL cholesterol goal (100 mg/dL); patients without CHD but with elevated LDL-C (130 mg/dL) and two or more other CHD risk factors are at high risk for developing CHD and have an LDL cholesterol goal of less than 130 mg/dL; patients free of CHD with high LDL cholesterol (160 mg/dL) but fewer than two other risk factors have a lower CHD risk and an LDL cholesterol goal of less than 160 mg/dL. Elevated triglyceride may be a marker for other factors that increase CHD risk. Raising HDL cholesterol, while not proven to be of benefit, is reasonable in patients at high CHD risk.

Distributions and trends of serum lipid levels among United States children and adolescents ages 4-19 years: data from the Third National Health and Nutrition Examination Survey.

BACKGROUND: Atherosclerosis begins in childhood and progresses into adulthood. The reduction of cardiovascular risk factors, such as elevated serum total cholesterol and low-density lipoprotein cholesterol (LDL-C) levels, in childhood may reduce cardiovascular morbidity and mortality in adulthood. Lipid distributions among children and adolescents were examined using the most recent nationally representative data. METHODS: Data from 7,499 examinees in NHANES III (1988-1994) were used to estimate mean and percentile distributions of serum total cholesterol, LDL-C, high-density lipoprotein cholesterol (HDL-C), and triglycerides in children and adolescents aged 4 to 19 years. The estimates were analyzed by age, sex, and race/ethnic groups. Trends in mean total cholesterol were examined for 12- to 17-year-olds using data from NHES III (1966-1970), NHANES I (1971-1974), and NHANES III (1988-1994). RESULTS: For children and adolescents 4 to 19 years of age, the 95th percentile for serum total cholesterol was 216 mg/dL and the 75th percentile was 181 mg/dL. Mean age-specific total cholesterol levels peaked at 171 mg/dL at 9-11 years of age and fell thereafter. Females had significantly higher mean total cholesterol and LDL-C levels than did males (P < 0.005). Non-Hispanic black children and adolescents had significantly higher mean total cholesterol, LDL-C, and HDL-C levels compared to non-Hispanic white and Mexican American children and adolescents. The mean total cholesterol level among 12- to 17-year-olds decreased by 7 mg/dL from 1966-1970 to 1988-1994 and is consistent with, but less than, observed trends in adults. Black females have experienced the smallest decline between surveys. CONCLUSIONS: The findings provide a picture of the lipid distribution among U.S. children and adolescents and indicate that, like adults, adolescents have experienced a fall in total cholesterol levels. Total cholesterol levels in U.S. adolescents declined from the late 1960s to the early 1990s by an average of 7 mg/dL. This information is useful for planning programs targeting the prevention of cardiovascular disease beginning with the development of healthy lifestyles in childhood.

The National Cholesterol Education Program: progress and prospects.

The National Cholesterol Education Program (NCEP) is a prime example of the role the National Heart, Lung, and Blood Institute has played, in its 50 years of existence, as a catalyst for translating research advances into improved clinical and public health practices. Since its inception in 1985, the NCEP has adhered to 2 principles in mounting educational campaigns for professionals and the public: building on a strong science base and working in partnership with other organizations. In slightly more than a decade, the NCEP has made significant progress toward its goal of reducing the prevalence of high blood cholesterol. The impact of cholesterol education is clearly visible in 4 major trends: increasing professional and public cholesterol awareness; declining dietary intakes of saturated fat, total fat, and cholesterol; falling serum cholesterol levels; and a continuing decline in coronary heart disease (CHD) mortality rates. Nevertheless, cholesterol levels are still being undertreated, especially in patients with CHD, and substantial scientific and educational challenges remain. As it looks forward to the 21st century, the NCEP plans to make continued progress by using emerging scientific developments and pursuing the powerful combination of cholesterol lowering in CHD patients and in primary prevention.

Adults aged 20 and older should have their cholesterol measured.

The guidelines of the National Cholesterol Education Program recommend that adults > or = 20 years of age should have their total and high-density lipoprotein cholesterol measured. This recommendation, which has been endorsed by representatives of > 40 medical and health organizations, is based on a large and diverse body of scientific evidence derived from animal, pathologic, genetic, biochemical, metabolic, and epidemiologic studies and clinical trials. Elevated cholesterol levels raise the risk of coronary heart disease (CHD) in men and women and in younger and older adults. Recent clinical trials have confirmed that cholesterol lowering reduces CHD morbidity and mortality and total mortality, without an increase in noncardiovascular mortality, in patients with and without CHD. Measuring cholesterol levels in adults > or = 20 years of age is necessary to provide an accurate assessment of CHD risk to an individual; to identify individuals who should lower their cholesterol levels, using diet and lifestyle changes as the primary treatment; and to reinforce population recommendations. Atherosclerosis begins early in life, and cholesterol levels in young adults predict CHD risk 30-40 years later. Cholesterol measurement can be used to motivate lifestyle changes that will reduce the long-term risk for CHD. Waiting until mid-life to find an elevated cholesterol loses a significant portion of the benefit. Cholesterol is a CHD risk factor in women and older adults, and recent trials show significant CHD risk reduction in these groups. While drug treatment is properly directed to patients with high CHD risk, in whom drugs are cost-effective, cholesterol measurement and lifestyle-based cholesterol lowering are necessary on a broader scale to reduce long-term CHD risk in adults aged > or = 20 years.

Prevalence of high blood cholesterol among US adults. An update based on guidelines from the second report of the National Cholesterol Education Program Adult Treatment Panel.

OBJECTIVE: To estimate the current levels and trends in the proportion of US adults with high blood cholesterol based on guidelines from the second report of the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP II). DESIGN: Nationally representative cross-sectional surveys. SETTING/PARTICIPANTS: Data for 7775 participants 20 years of age and older from phase 1 of the third National Health and Nutrition Examination Survey (NHANES III) (data collected from 1988 through 1991) and for 9797 participants 20 through 74 years of age from NHANES II (data collected from 1976 through 1980) were used. RESULTS: From the data collection period in NHANES II (1976 through 1980) to the period in NHANES III (1988 through 1991), the proportion of adults with high blood cholesterol levels (> or = 240 mg/dL [6.21 mmol bd) fell from 26% to 20%, while the proportion with desirable levels (< 200 mg/dL [5.17 mmol/L]) rose from 44% to 49%. Currently, using the ATP II guidelines and NHANES III data, 40% of all adults 20 years of age and older would require fasting lipoprotein analysis; and 29% of all adults would be candidates for dietary therapy (as compared with 36%, using NHANES II data). Based on 1990 population data, it is estimated that approximately 52 million Americans 20 years of age and older would be candidates for dietary therapy. Assuming that dietary intervention would reduce low-density lipoprotein (LDL) cholesterol levels by 10%, as many as 7% of all adult Americans (approximately 12.7 million) might be candidates for cholesterol-lowering drugs. This estimate reflects approximately 4 million adults with established coronary heart disease, of whom half are aged 65 years and older, and up to 8.7 million adults without established coronary heart disease, of whom up to 3.1 million are aged 65 years and older. CONCLUSIONS: Substantial progress has been made in reducing the prevalence of high blood cholesterol; yet a large proportion of all adults, approximately 29%, require dietary intervention for high blood cholesterol.

The National Cholesterol Education Program.

The National Cholesterol Education Program (NCEP) is a cooperative effort by the major health and medical organizations in the United States. The goal of the program is to reduce the prevalence of elevated blood cholesterol and thereby contribute to reducing coronary heart disease (CHD) morbidity and mortality. Through educational efforts aimed at professionals and the public, the NCEP seeks to raise awareness and understanding about high blood cholesterol as a risk factor for CHD and about the benefits of lowering elevated cholesterol as a means of preventing CHD.

The place of HDL in cholesterol management. A perspective from the National Cholesterol Educational Program.

The guidelines developed by the Adult Treatment Panel of the National Cholesterol Education Program identified low density lipoprotein (LDL) as the major atherogenic lipoprotein, and high levels of LDL-cholesterol as the primary target for cholesterol-lowering therapy. Low levels of high density lipoprotein (HDL)-cholesterol were recognized as a major risk factor for coronary heart disease. This report reexamines in depth the recommendations of the Adult Treatment Panel on HDL-cholesterol. Two major questions are discussed: (1) Should HDL-cholesterol levels be measured in all adults, as recommended for total cholesterol? (2) Should patients found to have a low serum HDL [corrected]-cholesterol level (less than 35 mg/dL [less than 0.91 mmol/L]) enter medical therapy to raise the level? The guidelines of the Adult Treatment Panel are reaffirmed as appropriate from the current perspective. These guidelines recommend that HDL-cholesterol levels be determined in patients deemed to be at high risk for coronary heart disease and suggest that HDL measurement is optional for individuals with borderline-high total levels. The guidelines of the Adult Treatment Panel recommend that low HDL-cholesterol levels be raised mainly by hygienic means (ie, smoking cessation, weight loss, aerobic exercise). When drug therapy is required for high LDL-cholesterol levels in the presence of low HDL levels, cholesterol-lowering drugs that concomitantly raise HDL should be given first priority.

Education of the patient with cardiac disease in the twenty-first century: an overview.

The current status of education, behavioral change, and use of technology identifies a need for professionals who can develop interactive educational programs and apply existing techniques in a cost-effective manner. The general public, including patients with cardiac disease, are sophisticated consumers of information technology and demand quality production. The challenge is to train specialists to produce educational programs, to instruct health professionals in use of these programs, to deliver appropriate messages, to teach needed skills to patients with cardiac disease, and to evaluate the outcomes. Unless incentives to restore cardiac patients to an optimal functional status with few recurrences and complications are as tangible as are incentives for treating acute cardiac illnesses, the appropriate use of technology to educate patients with heart disease is unlikely to develop. However, the trend to increased ambulatory care under prospective payment systems makes it likely that technology will be applied to improve the efficiency in maintaining health and preventing acute illness. The potential benefits to the nation are substantial.