Volume 111, Issue s43

Elevated low-density lipoprotein cholesterol (LDL-C) levels are a modifiable risk factor for the development of coronary heart disease (CHD), the leading cause of death in the United States. Treatments to lower these levels help decrease the risk of CHD events and reduce mortality rates in patients with existing CHD and those with no history of CHD. Rates of screening and treatment for high cholesterol levels have improved somewhat in recent years, but there is still room for substantial improvement, especially in patients at high risk of CHD, who benefit most from aggressive LDL-C–lowering therapies. The American Osteopathic Association Clinical Assessment Program, a Web-based program that measures physician performance by analyzing data abstracted from patient medical records and helps guide treatment decisions, is a tool to help physicians improve outcomes in patients with elevated LDL-C levels.

According to current guidelines from the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III), the target low-density lipoprotein cholesterol (LDL-C) level for patients with established coronary heart disease (CHD) or CHD risk equivalents is less than 100 mg/dL, with an optional target of less than 70 mg/dL. More recent data suggest, however, that the physiologically normal level of LDL-C and the level at which atherogenesis is initiated is much lower. Overall, the data convincingly demonstrate that LDL-C lowering is associated with a significant reduction in CHD events, regardless of preexisting CHD. The NCEP ATP III treatment guidelines, published in 2002 and updated in 2004, do not reflect more recent findings on intensive lipid-lowering therapy, which are likely be addressed in the NCEP ATP IV guidelines, scheduled to be released in 2011. Drug options for LDL-C lowering include statins (the drug of choice), bile acid sequestrants, nicotinic acid, fibrates, and selective cholesterol absorption inhibitors.

Improving clinical outcomes in patients at high risk for coronary heart disease (CHD) requires a multimodal approach, especially in patients with the metabolic risk factors that constitute the metabolic syndrome, which is associated with an elevated risk of CHD at all levels of low-density lipoprotein cholesterol (LDL-C). Achieving optimal clinical outcomes requires a comprehensive and aggressive therapeutic plan that includes pharmacotherapy and lifestyle changes. Effective pharmacotherapy for components of the metabolic syndrome (eg, hypertension, elevated LDL-C levels, prothrombotic state) is important in improving clinical outcomes, as is pharmacotherapy for glycemic control in patients with diabetes. Therapeutic lifestyle changes recommended for treatment of metabolic syndrome include smoking cessation, exercise programs, nutritional counseling, and weight control. Patient questionnaires are an effective way to help tailor recommendations to individual patients and thereby increase compliance. Clinicians can also help motivate patients by offering practical tips for modifying diet and eating habits and explaining all the benefits of exercise. These combined approaches can be used to help more patients achieve their lipid goals, and new pharmacologic therapies currently under investigation may further expand available treatment options.