INTRODUCTION

The Third Report of the Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III, or ATP III) from the National Cholesterol Education Program (NCEP) has summarized the current recommendations for the management of high serum cholesterol [1]. Guidelines from various organizations differ in their applicability, risk estimates, and recommendations [2].

The ATP III guidelines are based upon epidemiologic observations that showed a graded relationship between the total cholesterol concentration and coronary risk (figure 1A-C) [3]. They are influenced by the absence (primary prevention) or presence (secondary prevention) of preexisting coronary heart disease (CHD) [4]. A meta-analysis of 38 primary and secondary prevention trials found that for every 10 percent reduction in serum cholesterol, coronary heart disease mortality was reduced by 15 percent and total mortality risk by 11 percent [5]. No increase in noncoronary heart disease mortality was seen.

This topic presents recommendations from ATP III and the NCEP. UpToDate's recommendations for managing lipid abnormalities in primary and secondary prevention are discussed in detail separately. (See "Treatment of lipids (including hypercholesterolemia) in primary prevention" and "Treatment of lipids (including hypercholesterolemia) in secondary prevention".)

IDENTIFICATION OF PATIENTS AT RISK

ATP III recommendations for risk assessment — The ATP III recommendations for the treatment of hypercholesterolemia are based upon the LDL-cholesterol (LDL-C) fraction and are influenced by the coexistence of CHD and the number of cardiac risk factors [1,6]. There are five major steps to determining an individual's risk category, which serves as the basis for the treatment guidelines [1].

Step 1 — The first step in determining patient risk is to obtain a fasting lipid profile; the results are classified as shown in the table (table 1).