The recommendations of the report have been eagerly awaited by the diabetes community for many years. In the first report of the National Cholesterol Education Program the emphasis was on lowering of LDL cholesterol as a primary prevention strategy in people with high LDL cholesterol levels (> 160 mg/dl) or with levels of 130-159 mg/dl plus at least two coronary risk factors. Diabetes was viewed as a coronary risk factor and received minimal rating in the Framingham risk score. Yet the major cause of death in type 2 diabetes was clearly cardiovascular disease, and it was known that cardiovascular risk was well in excess of the risk in non-diabetics. The report did not recognize this issue. Simultaneously, Gerald Reaven demonstrated in his Banting Lecture at the ADA in 1988, that “syndrome X” was associated with a high cardiovascular risk. This observation catalyzed intense interest in this entity among diabetes specialists.
ATP II focused on patients with established coronary artery disease and recommended intensive LDL cholesterol (LDL-C) lowering to < 100 mg/dl. Diabetes was not viewed as a separate high-risk issue. Meanwhile, evidence continued to mount indicating that most people with type 2 diabetes had an extraordinarily high-risk for coronary artery events. Finally, it was conclusively demonstrated that the risk for the first heart attack in type 2 diabetes equaled that in nondia-betics who had already had a myocardial infarction. Furthermore, although promising reductions in the risk for cardiovascular events were seen in the general population over the past 2-3 decades, little benefit was seen in men with diabetes, and the cardiovascular event rates actually increased in women with diabetes over the same period.
The ATP III Report gives an evidenced-based approach that focuses first on LDL-C as the primary target of therapy. The major change in approach is the recognition that diabetes is a coronary heart disease (CHD) equivalent rather than merely a cardiovascular risk factor. Thus, people with diabetes are to be treated as if they had CHD, and aggressive lowering of LDL-C to 100 mg/dl or below is the goal. This guideline accord with earlier recommendations made by the ADA and removes any confusion that may have existed in the past.
The ADA approaches lipid therapy in adults with diabetes by defining levels of cardiovascular risk (Table 12). The ADA then defines the LDL-C goal as < 100 mg/dl, which is to be achieved by exercise, medical nutrition, and pharmacologic therapy (if needed) in patients with or without cardiovascular disease.
A specific recommendation for patients with metabolic syndrome or diabetes who have LDL-C levels > 130 mg/dl is to initiate drug therapy (i.e., statins) if therapeutic lifestyle changes (TLC) cannot achieve an LDL-C goal of < 100 mg/dl. In the case of intermediate LDL-C levels of 100-129 mg/dl, both the ADA and the NCEP (ATP III) make similar TLC recommendations. However, if this approach fails, the ADA favors pharmacologic treatment with a statin, and the NCEP (ATP III) group gives the option of statin therapy or drugs that primarily modify triglycerides and HDL-C (nicotinic acid or fibrates). Clinical judgment must be used for patients in this category.
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LIPIDS/LIPOPROTEINS: A CONSENSUS FOR INTENSIVE MANAGEMENT OF LIPIDS AND LIPOPROTEINS IN TYPE 2 DIABETES – REPORTS OF THE NATIONAL CHOLESTEROL EDUCATION PROGRAMThe recommendations of the report have been eagerly awaited by the diabetes community for many years. In the first report of the National Cholesterol Education Program the emphasis was on lowering of LDL cholesterol as a primary prevention strategy in people with high LDL cholesterol levels (> 160 mg/dl) or with levels of 130-159 mg/dl plus at least two coronary risk factors. Diabetes was viewed as a coronary risk factor and received minimal rating in the Framingham risk score. Yet the major cause of death in type 2 diabetes was clearly cardiovascular disease, and it was known that cardiovascular risk was well in excess of the risk in non-diabetics. The report did not recognize this issue. Simultaneously, Gerald Reaven demonstrated in his Banting Lecture at the ADA in 1988, that “syndrome X” was associated with a high cardiovascular risk. This observation catalyzed intense interest in this entity among diabetes specialists.ATP II focused on patients with established coronary artery disease and recommended intensive LDL cholesterol (LDL-C) lowering to < 100 mg/dl. Diabetes was not viewed as a separate high-risk issue. Meanwhile, evidence continued to mount indicating that most people with type 2 diabetes had an extraordinarily high-risk for coronary artery events. Finally, it was conclusively demonstrated that the risk for the first heart attack in type 2 diabetes equaled that in nondia-betics who had already had a myocardial infarction. Furthermore, although promising reductions in the risk for cardiovascular events were seen in the general population over the past 2-3 decades, little benefit was seen in men with diabetes, and the cardiovascular event rates actually increased in women with diabetes over the same period.The ATP III Report gives an evidenced-based approach that focuses first on LDL-C as the primary target of therapy. The major change in approach is the recognition that diabetes is a coronary heart disease (CHD) equivalent rather than merely a cardiovascular risk factor. Thus, people with diabetes are to be treated as if they had CHD, and aggressive lowering of LDL-C to 100 mg/dl or below is the goal. This guideline accord with earlier recommendations made by the ADA and removes any confusion that may have existed in the past.The ADA approaches lipid therapy in adults with diabetes by defining levels of cardiovascular risk (Table 12). The ADA then defines the LDL-C goal as < 100 mg/dl, which is to be achieved by exercise, medical nutrition, and pharmacologic therapy (if needed) in patients with or without cardiovascular disease.A specific recommendation for patients with metabolic syndrome or diabetes who have LDL-C levels > 130 mg/dl is to initiate drug therapy (i.e., statins) if therapeutic lifestyle changes (TLC) cannot achieve an LDL-C goal of < 100 mg/dl. In the case of intermediate LDL-C levels of 100-129 mg/dl, both the ADA and the NCEP (ATP III) make similar TLC recommendations. However, if this approach fails, the ADA favors pharmacologic treatment with a statin, and the NCEP (ATP III) group gives the option of statin therapy or drugs that primarily modify triglycerides and HDL-C (nicotinic acid or fibrates). Clinical judgment must be used for patients in this category.*170\357\8*