The AHA Guidelines and Scientifi c Statements Handbook
for updated ATP III cutpoints for these factors)
[17]. Treatment of the metabolic syndrome places
priority on lifestyle therapy (i.e., weight reduction
and increased physical activity). For the individual
risk factors, treatment should follow currently estab-
lished guidelines. Subgroup analysis of several clini-
cal trials demonstrate that patients with the metabolic
syndrome respond as well or better with CVD risk
reduction to established therapies compared to
patients without the syndrome.
Table 10.8 Unresolved issues in cholesterol management
Topic Unresolved issue Consensus views
Lifetime risk
management
Should cholesterol lowering with drugs be
introduced earlier in life?Epidemiological and genetic studies indicate that a lifetime of low
LDL levels is accompanied by very low rates of CHD. However, the
long-term safety and tolerance of cholesterol lowering drugs remains
to be documented.Subclincal
atherosclerosis
imaging for risk
assessment
Should arterial imaging be used to select
persons for earlier intervention with
cholesterol-lowering drugs?Subclinical atherosclerosis, whether coronary or carotid, is
accompanied by increased risk for CVD. However, evidence that
wide-spread, routine imaging would be effi cacious in prevention of
CVD has not been adequately documented. Nonetheless, imaging is
promising for risk assessment for properly selected persons.Emerging risk factors What is the role of emerging risk factors in
global risk assessment for CVD? Examples
include apolipoproteins, infl ammatory
markers, insulin-resistance markers.
Several emerging risk factors have statistical power to predict CVD
events. Whether their predictive power is independent of established
factors has been controversial. Nonetheless, because of their
predictive power physicians have the option of using emerging risk
factors as adjunctive predictors in addition to risk-factor assessment
with standard risk factors.Women: ages 45–74
years
Are women candidates for primary
prevention with cholesterol-lowering
drugs?Cholesterol-lowering has proven to be effi cacious in secondary
prevention in women. Primary prevention trials in women have been
too limited to draw evidence-based conclusions. Even so, most
authorities recommend drug therapy when global risk is high enough
to justify drug therapy in men.Elderly: men ≥ 65
years; women ≥ 75
years
Are older persons candidates for primary
prevention with cholesterol-lowering
drugs?Cholesterol-lowering has been proved to be effi cacious in secondary
prevention in older persons. Primary prevention trials in the elderly
have been too limited to draw evidence-based conclusions. Even so,
most authorities recommend drug therapy when global risk is high
enough to justify drug therapy in middle-aged persons.Younger adult: men
20–35 years; women
20–45 years
Are younger adults candidates for primary
prevention with cholesterol-lowering
drugs?There are no long-term primary prevention trials that start in your
adulthood. There is growing interest in use of drugs for lifetime
prevention, but at present, drug generally limited to young adults
with more severe dyslipidemias.Different and ethnic
groups
Should cholesterol guidelines be applied
equally to all ethnic groups?Most authorities agree that all ethnic groups should be treated
equally in spite of a lack of clinical trials in all such groups.Other unresolved issues
Table 10.8 addresses a series of issues that have
not been resolved. Clinical practice requires
that decisions be made regarding the questions
addressed. To date clinical trials are limited in
these areas. For this reason, clinical judgment is
required for treatment decisions. The table out-
lines current consensus of the experts, although
disagreements among authorities can be found in
the literature.