Volume 103, Issue s1

Coronary heart disease (CHD) remains the leading cause of death in the United States with more than 40% of all deaths each year directly attributed to the disease. Current evidence suggests that early identification and aggressive modification of risk factors offer the most promising approach to reducing the burden of CHD. Dyslipidemia has been identified as the primary risk factor leading to the development of CHD. It is estimated that nearly 65 million Americans require some form of lipid-modification therapy. The National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) set of guidelines released in May 2001 provides physicians with evidence-based recommendations on the classification, diagnosis, and treatment of lipid disorders. New features of the guidelines include a scoring system for calculating CHD risk, as well as the identification of CHD risk equivalents, lower treatment target goals, and an emphasis on conditions conferring a higher risk for CHD, such as the metabolic syndrome. The ATP III emphasis on risk assessment substantially increases the number of patients considered at risk for CHD and will expand the number eligible for lifestyle and drug interventions. This article highlights the new recommendations and reviews the impact of ATP III on osteopathic physicians.

Despite increased attention placed on the identification and treatment of dyslipidemia, this condition remains undiagnosed and untreated in a significant number of patients. The recently released National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) set of cholesterol management guidelines increases to more than 65 million the number of Americans eligible for lipid-modifying therapy. Recent data, however, suggest that even with the availability of multiple regimens with proven efficacy, as many as 50% of all patients do not have their cholesterol assessed and less than 45% receive lipid-modifying therapy. In addition, less than 25% of patients are treated to their NCEP target low-density lipoprotein cholesterol (LDL-C) level. Persistence with therapy is another challenge, as more than 70% of patients fail to maintain their therapy beyond 12 months. If a realistic attempt is to be made to reduce the risk of coronary heart disease (CHD) among Americans, diagnosis of dyslipidemia and treatment to therapeutic targets must be improved. This artide discusses the underdiagnosis and undertreatment of lipid disorders and reviews the role of osteopathic physicians in strategies achieving ATP III LDL-C goals.

In the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) guidelines, the emphasis of lipid-lowering therapy is placed on reaching target plasma low-density lipoprotein cholesterol (LDL-C) levels in order to reduce the risk for coronary heart disease (CHD). Although therapeutic lifestyle changes can have a positive effect on LDL-C levels, the ATP III recognizes that a majority of patients with dyslipidemia will also require drug therapy to achieve lipid targets. Currently, only a small percentage of patients, including those with CHD, are reaching goal. Early aggressive use of the effective lipid-lowering agents currently available is critical to achieve target lipid levels in a greater number of patients. Use of drug combinations further enhances the likelihood of achieving target lipid levels. Ideally, the combination of therapeutic modalities used both the endogenous and exogenous pathways of cholesterol synthesis to reduce the amount produced in the body, as well as the amount absorbed from the diet. This article reviews the pharmacotherapeutic effects of combination therapy, summarizes the strengths and weaknesses of current lipid-lowering drug combinations, and identifies the potential impact of the novel cholesterol absorption inhibitor ezetimibe on the LDL-C treatment algorithm.

The relationship between increased levels of cholesterol and elevated risk for coronary heart disease (CHD) has been described in many epidemiologic and well-designed prospective trials. Since first being elucidated by the Coronary Primary Prevention Trial, reducing levels of blood cholesterol results in a corresponding reduction in CHD risk has been demonstrated by numerous trials. The evidence now indicates that cholesterol reduction by any number of means confers up to a 35% reduction in total mortality, coronary mortality, coronary artery procedures, stroke, and other CHD-related events. This article reviews data that demonstrate cholesterol reduction decreases CHD risk, discusses current and emerging treatment modalities, and describes the methods healthcare practitioners can use to enhance lipid treatment outcomes. It also identifies educational tools that can be used to empower patients to improve their compliance and become actively involved in reducing their CHD risk.

The National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) guidelines call for more aggressive lowering of low-density lipoprotein cholesterol (LDL-C) and will substantially increase the number of patients eligible for lipid-lowering therapy. Statins, the current treatment standard, have proven to be highly efficacious in lowering LDL-C and reducing coronary heart disease (CHD) risk. Because some patients are unable to tolerate 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) or they are not candidates for statin therapy, however, other cholesterol-lowering modes of therapy are needed. Currently available nonstatin drugs often do not reliably reduce LDL-C to a desired extent or are limited in their safety and tolerability. Ezetimibe, a novel lipid-lowering agent until recently in phase III development, is the first in a new class of selective cholesterol absorption inhibitors and offers a promising new approach to the treatment of dyslipidemia. This article reviews the cholesterol metabolic pathways and the mechanism of action of the currently available lipid-modifying agents and introduces ezetimibe, the first selective cholesterol absorption inhibitor.