National cholesterol education program - Heart Health - Brief Article

Nutrition Research Newsletter, Oct, 2001

The National Cholesterol Education Program (NCEP) Adult Treatment Panel publicizes guidelines to help health care practitioners treat patients with lipid disorders. Guidelines identify LDL cholesterol concentrations as a major cardiovascular risk predictor and specify treatment goals based on LDL levels. However, data from the National Health and Nutrition Examination Survey (NHANES III) revealed that 57% of adults older than age 20 and having two or more risk factors were not at LDL target level and 85% of patients with coronary artery disease (CAD) were not at target level. Many facilities have developed specialized clinics in attempts to improve the rate of NCEP goal attainment.

The Naval Hospital in Jacksonville developed a Lipid Disorder Clinic in 1997, using recommendations of the NCEP treatment panel as the basis for treatment. The purpose of the clinic was to optimize the care for patients with dyslipidemia by providing appropriate monitoring, education, and followup. The lipid clinic operates two half days per week and is staffed by a clinical pharmacist. An internal medicine department physician provides medical supervision to the clinic. Patients were eligible to be enrolled in the clinic by any health care provider within the facility. An LDL goal was determined and recorded in the clinic chart. All patients were offered a formal dietary consultation with a registered dietitian, and the American Heart Association Step 1 or 2 diet was prescribed for 3 to 6 months. Drug therapy may have been initiated concurrently in accordance with the NCEP recommended guidelines. Patients were evaluated by the clinic every 3 months until NCEP goal was met.

This retrospective, case-matched study was designed to compare 41 patients managed in the formal lipid clinic and 41 patients managed elsewhere in the system (control group). This study sample size was calculated to detect a 20% difference with 80% power and 95% confidence. The primary endpoint was NCEP LDL goal attainment. Clinic patients were randomly selected and matched retrospectively to facility patients for whom cholesterol determinations were ordered. Patients were matched according to baseline LDL value, sex, and age.

Clinic patients required a significantly greater reduction in LDL to reach NCEP goal. In addition, the clinic group had significantly more patients with an LDL goal of 100 mg/ dL and fewer with a goal of 160 mg/dL than the facility group. This was the result of the significantly greater number of risk factors present in clinic patients versus facility control patients. Clinic patients were found to have significantly greater LDL reduction after the 6-month visit, resulting in a lower final LDL. Sixty-six percent of the clinic patients achieved their NCEP goal, compared with 41% of the control patients. Significantly more patients in the clinic group were treated according to NCEP guidelines. The percent LDL reduction achieved by the clinic health care providers was an average of 26%. Facility providers treating the control patients achieved only an average of 6% reduction in LDL. Of patients eligible for pharmacotherapy according to the NCEP guidelines, 26 of 40 clinic patients and 11 of 36 nonclinic patients were treated with medication.

The results of the study suggest that a formally structured lipid clinic has a significant positive impact on the percentage of patients reaching NCEP LDL goal, following NCEP guidelines for initiating and titrating drug therapy, and overall percentage reduction in LDL. This has been shown to significantly improve outcomes for patients with and without CAD.

S. Yates, L. Annis, J. Pippins, S. Walden. Does a Lipid Clinic Increase Compliance With National Cholesterol Education Program Treatment Guidelines? South Med J 94(9): 907-909 (September 2001) [Correspondence: Scott Yates, MD, MBA, North Texas Medical Research, 6053 Main St., Ste. 210, The Colony, TX 75056-2062]