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CLINICAL STUDIES

The relative influence of secondary versus primary prevention using the National Cholesterol Education Program Adult Treatment Panel II guidelines

Lee Goldman, MD, MPH, FACC^*, Pamela Coxson, PhD^*, Maria G. M. Hunink, MD, PhD, Paula A. Goldman, MPH, Anna N. A. Tosteson, ScD, Murray Mittleman, DrPh, MDCM^||, Lawrence Williams, MS^¶ and Milton C. Weinstein, PhD

^* Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California, USA
Department of Health Sciences, University of Groningen, Groningen, the Netherlands
Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
Department of Clinical Research, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
^|| Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
^¶ Brigham and Women’s Hospital, Boston, Massachusetts, USA

Manuscript received October 6, 1998; revised manuscript received April 2, 1999, accepted May 14, 1999.

Reprint requests and correspondence: Dr. Lee Goldman, Department of Medicine, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, California 94143-0120
goldman{at}medicine.ucsf.edu

OBJECTIVES

This study was undertaken to project the population-wide effect of full implementation of the Adult Treatment Panel (ATP) II guidelines of the National Cholesterol Education Program (NCEP).

BACKGROUND

The ATP II has proposed guidelines for cholesterol reduction, but the long-term epidemiologic influence of its components has not been fully examined.

METHODS

We used a calibrated, validated simulation of the U.S. population, aged 35 to 84 years to estimate the potential for the NCEP guidelines, under varying assumptions, to reduce coronary heart disease morbidity and mortality and overall mortality from the years 2000 to 2020.

RESULTS

Primary prevention would yield only about half of the benefits of secondary prevention despite requiring nearly twice as many person-years of treatment. The projected increase in quality-adjusted years of life per year of treatment for secondary prevention was 3- to 12-fold higher than for primary prevention. To yield population-wide epidemiologic benefits equivalent to NCEP recommendations for secondary prevention, primary prevention would require a nearly sixfold increase in the number of persons treated compared with NCEP recommendations. All benefits of universal success of the NCEP primary prevention "screen and treat" guidelines could be achieved by a 11 mg/dl (8%) population-wide reduction in low-density lipoprotein cholesterol levels among persons without preexisting coronary heart disease.

CONCLUSIONS

The NCEP guidelines for targeted primary prevention can be a useful component of a rational public health strategy, but only as a complement to the more appealing strategies of secondary prevention and "across-the-board" programs to lower all cholesterol levels.

Abbreviations and Acronyms   ATP = Adult Treatment Plan   HDL = high-density lipoprotein   LDL = low-density lipoprotein   NCEP = National Cholesterol Education Program   NHANES = National Health and Nutrition Examination Survey

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