Non–High-Density Lipoprotein Cholesterol and Guidelines for Cholesterol Lowering in Recent History

Stanley S. Levinson, PhD


Lab Med. 2020;51(1):14-23. 

In This Article

Replacement of the NCEP With Consensus Committees in 2013

In 2013, the ACC and AHA released new guidelines from an expert group;[1] these guidelines replace the ATP. The ATP IV Committee transitioned to joining the members of the ATP IV expert group, who were working on, but had not yet completed, ATP IV. The term coronary heart disease, used in the ATP guidelines, was replaced with the term atherosclerotic cardiovascular disease (ASCVD). The Committee defined 4 treatment groups, as shown in Table 1. These guidelines were based largely on evidence obtained from RCTs. The guidelines did not speculate on evidence from other types of trials. The Expert Panel was unable to find evidence from RCTs that lowering of LDLC or non-HDLC concentrations to target values reduces risk of ASCVD, as had been suggested in the ATP reports.[1] Nor did the panel find sufficient evidence from RCTs that drugs other than statins should be used to reduce risk. Therefore, the 2013 Committee focused on the intensity of statin treatment, as shown in Table 1 and Table 2.

The committee also developed a risk calculator (Omnibus Risk Estimator) that is available at!/calculate/therapy or can be downloaded as an MS Excel (Microsoft Corporation) program at under the heading ASCV risk calculator. This calculator provides the 10-year risk for persons aged 20 to 79 years and the lifetime risk for persons aged 40 to 59 years, compared with optimal risk.

The characteristics entered into the calculator are sex; age; race; total cholesterol; HDLC; and systolic blood pressure, on treatment for high blood pressure, diabetes mellitus, and smoking. Although the ATP Panels relied largely on the Framingham Study 10-year risk scores, the Omnibus estimator is based on multivariate equations that were developed from 9 longstanding population-based cohort studies funded by the National Heart Lung and Blood Institute. The study participants included apparently healthy white, African American, and Hispanic women and men, aged 40 to 79 years.[23]