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November 21, 2001

Guidelines for Diagnosis and Treatment of High Cholesterol

Author Affiliations

Stephen J.LurieMD, PhD, Senior EditorIndividualAuthorJody W.ZylkeMD, Contributing EditorIndividualAuthor

JAMA. 2001;286(19):2400-2402. doi:10.1001/jama.286.19.2398

To the Editor: The guidelines of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel [ATP] III)1 are too complex for use in primary care. It will be the rare family physician who takes time to figure out a Framingham Risk Score.

It is well known that low-density lipoprotein cholesterol (LDL-C) is atherogenic and that high-density lipoprotein cholesterol (HDL-C) is antiatherogenic, so combining LDL and HDL into a fraction, such as the cholesterol retention fraction (CRF, defined as [LDL−HDL]/LDL), gives a measure of the atherogenic-antiatherogenic balance. A higher systolic blood pressure (SBP) also conveys risk. Cigarette smoking may well be the most important risk factor for atherothrombotic disease.2 Plotting CRF and SBP (Figure 1), a threshold line can be drawn with defining loci (CRF = 0.74, SBP = 100; and CRF = 0.49, SBP = 140) below which, in the absence of cigarette smoking, atherothrombotic disease is rare (when it does occur, it does so late in life).2 In 8 published angiographic trials of atherosclerotic plaque regression, bringing the CRF and SBP below the threshold line resulted in angiographic stabilization/regression of coronary artery plaque in a minimum of 75% of cases.3 Such a graph is less complex than the new guidelines, and more likely to be widely used.