Impact of evidence-based "clinical judgment" on the number of American adults requiring lipid-lowering therapy based on updated NHANES III data

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 num ber of Americans requiring lipid-lowering therapy based on ATP II cut point s. However, the guidelines recommend using clinical judgment to determine w hether to initiate drug therapy in individuals whose low-density lipoprotei n cholesterol levels remain above treatment goals with diet therapy but bel ow the initiation level for drug therapy. Methods: We analyzed updated (1988-1994) National Health and Nutrition Exam ination 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-den sity lipoprotein cholesterol level and requiring drug therapy using cut poi nts 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 rec ommend clinical judgment, the estimate increases to 28.4 million. The large st 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 indi viduals 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 safe ty and benefit of lipid-lowering therapy. The large number of individuals a t high risk for coronary heart disease emphasizes the need for cost-effecti ve therapy to extend treatment to the greatest number of individuals who ma y benefit.