Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)

James I. Cleeman, M.D.
Coordinator
National Cholesterol Education Program
May 15, 2001

Press Conference Remarks

Release of the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III)

Thank you, Dr. Grundy. I would like to comment on the significance and implications of the ATP III guidelines and describe what the NCEP is doing to speed their adoption into actual practice.

As you heard from Dr. Grundy, one of the central new features of ATP III is that it identifies individuals who are at high risk for a heart attack and recommends that they embark on intensive cholesterol-lowering treatment with lifestyle changes and with drugs, if needed. It turns out that there are many people whose high level of risk has not been recognized before. Our press release and Dr. Lenfant's remarks state that, compared with the previous guidelines (ATP II, 1993), the number of adults who need dietary therapy has increased from 52 million to 65 million, and the number who would benefit from drug treatment has risen from 13 million to 36 million. This increase is not because the ATP III panel decided to raise these numbers. Instead, it is the result of evidence showing that there are millions of Americans at high risk for a heart attack.

ATP III calls for recognizing that several conditions carry the highest level of risk: heart disease itself, diabetes, and multiple (2 or more) risk factors that confer a greater than 20% risk for having a heart attack within 10 years. Just below this highest level of risk is a group of persons who have multiple risk factors and a 10-year heart attack risk of 10-20%. In previous guidelines, people with diabetes or multiple risk factors would not have received as intensive treatment as in ATP III because their true level of risk was not fully appreciated, nor was there a method for assessing 10-year risk. The thorough review of the evidence carried out by the ATP III panel has established that these individuals require more aggressive cholesterol lowering treatment than was previously recommended.

If you look in your press packets, you will find a table with the percentage of American adults in each of 4 risk categories for whom therapeutic lifestyle changes (TLC) and drug treatment are recommended. You can see an interesting contrast.

VISUAL 1

The four categories of risk are: 1) heart disease and its risk equivalents (diabetes and multiple risk factors with a greater than 20% risk for a heart attack within 10 years); 2) multiple risk factors with a 10-year risk of 10-20%; 3) multiple risk factors with a 10-year risk of less than 10%; and 4) zero or 1 risk factor.

Overall, as you see in the left-hand column, 33% of American adults (about 65 million people) need TLC, meaning therapeutic lifestyle changes, including a cholesterol-lowering diet. The percentages in the four categories are pretty evenly distributed. The top two risk categories account for about 18 of the 33%, and the bottom two categories account for about 15 of the 33%. In other words, diet and TLC, which is the mainstay of cholesterol-lowering treatment, is recommended for both higher and lower risk persons.

In the right-hand column, the overall percentage of adults for whom drug treatment is recommended is 18.4% (about 36 million people). In contrast to TLC, however, drug treatment is concentrated in the top 2 categories. They account for about 15 of the 18.4%, while the bottom 2 categories account for only 3 to 4 of the 18.4%. In other words, drug treatment is recommended mainly for persons at higher risk for a heart attack. ATP III thus targets drug treatment to the people who will gain the greatest benefit from it. The increase in the number of people who require drug treatment reflects the high level of heart disease risk among Americans.

Even though the most aggressive form of cholesterol lowering is concentrated in people who have a high 10-year risk, it is important to emphasize that individuals who appear to be at low risk in the short term may have quite a high risk in the long term. A young adult with multiple risk factors or a very high LDL cholesterol will usually have a 10-year risk that is not very high because risk tends to rise with age. However, 10 years hardly defines the entire horizon for such a young adult, whose chance of having a heart attack in the next several decades is greatly increased. For this reason, the ATP III approach looks at overall risk for heart disease, which means risk in both the short term and long term. To gauge their overall risk, ATP III recommends that all Americans know their cholesterol levels (especially their LDL levels) and other risk factors and take action now to prevent that future heart attack. Every risk factor needs to be treated.

One of ATP III's important contributions is to recommend a more effective set of lifestyle changes (TLC) than was used before. The new TLC diet does away with the previous stepped approach for reducing the amount of saturated fat and cholesterol consumed and goes right to the more intensive level of less than 7% of calories from saturated fat and less than 200 milligrams a day of dietary cholesterol. TLC also boosts the diet's LDL-lowering power by adding foods that contain plant stanols or sterols or are rich in viscous (soluble) fiber. Moreover, TLC emphasizes the need for weight control and increased physical activity for everyone but especially for those with a cluster of risk factors known as the metabolic syndrome. TLC is the first line of therapy for a high cholesterol and, with the turbo-charge that ATP III gives it, it will be significantly more effective in lowering LDL than the previous lifestyle recommendations. Using all of the components of TLC can lower LDL by 20% or more, which is quite a substantial and beneficial reduction. TLC will also improve triglyceride and HDL levels.

The ATP III guidelines can make a major contribution to reducing the toll from heart disease. But they can do so only if they are adopted and used by physicians, other health professionals, and patients. We know that previous guidelines, whether for high blood cholesterol or other conditions, have not been fully implemented. For example, it is widely agreed that cholesterol lowering markedly reduces the risk for a heart attack in patients with heart disease. Over 80% of such patients would benefit from cholesterol lowering, but only about 50% are being treated with lifestyle or drugs, and only about 20% are being treated aggressively enough to reach their goal LDL level.

To improve this situation, NCEP and NHLBI are taking a series of steps to foster speedy adoption of the ATP III guidelines into practice. First, we have developed products to make the guidelines easily accessible. As you have heard, the Executive Summary of ATP III will appear in tomorrow's issue of JAMA, which will bring it to the attention of most physicians. The Executive Summary is posted on our Web site and will be printed for wide distribution. We have also prepared a quick desk reference, called "ATP III At-A-Glance," that highlights the recommended action steps. Second, we have developed a set of Web-based and electronic tools to help physicians and other health professionals implement the guidelines. These tools include: 1) a Palm OS interactive tool to apply ATP III at the point of care; 2) a 10-year risk calculator; and 3) a set of PowerPoint slides for teaching ATP III to professional audiences. For patients, we have a new brochure called "High Blood Cholesterol–What You Need to Know;" an online 10-year risk calculator aimed at lay users; and an updated Web site on cholesterol lowering called "Live Healthier, Live Longer." I'd now like to demonstrate to you the Palm OS interactive tool and the patient Web site.

DEMO

NHLBI/NCEP is also partnering with the National Committee for Quality Assurance (NCQA) to enhance the reach and impact of the guidelines. NHLBI and NCQA will cosponsor a national conference for practitioners on ATP III implementation. "Advances in Cholesterol Management: Putting the New National Cholesterol Education Program Guidelines Into Practice" will be held in Washington, D.C., on June 4-5. The conference will be a forum to highlight the new aspects of ATP III and convey practical ways of applying the guidelines. The new tools I've mentioned will be available to the participants. NCQA's involvement will help the ATP III guidelines reach practitioners and health care managers, and NCQA's HEDIS (Health-plan Employer Data and Information Set) performance measures can help foster use of the guidelines. In all these ways, we are aiming to accelerate the pace at which the ATP III guidelines are adopted in routine practice.

The ATP III guidelines have the potential to greatly improve cholesterol control and heart disease outcomes. If practitioners fully adopt and implement ATP III, it will significantly reduce illness and death from heart disease and improve the health of Americans. The challenge before all of us is to help realize this potential.


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