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Terry A. Jacobson, MD; Godfrey G. Griffiths, BComm(Hons); Cristina Varas, MD, MS; Douglas Gause, DrPH; Jennifer C. Y. Sung, PharmD; Christie M. Ballantyne, MD

Arch Intern Med. 2000;160:1361-1369.

Background  When the National Cholesterol Education Program Adult Treatment Panel II (ATP II) guidelines were published, National Health and Nutrition Examination Survey III data for 1988 to 1991 were used to estimate the number of Americans requiring lipid-lowering therapy based on ATP II cut points. However, the guidelines recommend using clinical judgment to determine whether to initiate drug therapy in individuals whose low-density lipoprotein cholesterol levels remain above treatment goals with diet therapy but below the initiation level for drug therapy.

Methods  We analyzed updated (1988-1994) National Health and Nutrition Examination Survey III data, based on a sample of 6796 adults aged 20 years and older, to estimate the numbers of American adults with an elevated low-density lipoprotein cholesterol level and requiring drug therapy using cut points vs clinical judgment as specified in ATP II guidelines.

Results  Assuming a 10% low-density lipoprotein cholesterol reduction with diet, an estimated 10.4 million American adults require drug therapy based on ATP II cut points. If we include individuals for whom the guidelines recommend clinical judgment, the estimate increases to 28.4 million. The largest increase occurs in individuals without known coronary heart disease but with 2 or more risk factors: from 5.5 to 17.5 million. These high-risk individuals have low-density lipoprotein cholesterol concentrations similar to those in patients with coronary heart disease.

Conclusions  Since the ATP II guidelines were published, clinical judgment has been informed by abundant clinical trial evidence establishing the safety and benefit of lipid-lowering therapy. The large number of individuals at high risk for coronary heart disease emphasizes the need for cost-effective therapy to extend treatment to the greatest number of individuals who may benefit.

From the Department of Medicine, Emory University School of Medicine, Atlanta, Ga (Dr Jacobson); PPD Pharmaco Corporation, Morrisville, NC (Mr Griffiths); Novartis Global Epidemiology, Barcelona, Spain (Dr Varas); Novartis Health Care Management, East Hanover, NJ (Drs Gause and Sung); and Department of Medicine, Baylor College of Medicine, Houston, Tex (Dr Ballantyne). Mr Griffiths is an employee of PPD Pharmaco Corporation, Morrisville, NC, which received funding from Novartus Pharmaceuticals Corporation for performing data analysis of the third National Health and Nutrition Examination Survey data set.

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