Consensus Development Conference Statement December 10-12, 1984 This statement is more
than five years old and is provided solely for historical purposes. Due to
the cumulative nature of medical research, new knowledge has inevitably
accumulated in this subject area in the time since the statement was
initially prepared. Thus some of the material is likely to be out of date,
and at worst simply wrong. For reliable, current information on this and
other health topics, we recommend consulting the National Institutes of
Health's MedlinePlus http://www.nlm.nih.gov/medlineplus/.
This statement was originally published as: Lowering Blood Cholesterol To Prevent Heart
Disease. NIH Consens Statement 1984 Dec 10-12; 5(7):1-11.
For making bibliographic reference to the
statement in the electronic form displayed here, it is recommended that
the following format be used: Lowering Blood Cholesterol To Prevent Heart
Disease. NIH Consens Statement Online 1984 Dec 10-12 [cited year month
day]; 5(7):1-11.
Coronary heart disease is responsible for
more than 550,000 deaths in the United States each year. It is responsible
for more deaths than all forms of cancer combined. There are over 5.4
million Americans with symptomatic coronary heart disease and a large
number of others with undiagnosed coronary disease, many of them young and
highly productive. It has been estimated that coronary heart disease costs
the United States over $60 billion a year in direct and indirect costs. Coronary heart disease is due to
atherosclerosis, a slowly progressive disease of the large arteries that
begins early in life but rarely produces symptoms until middle age. Often
the disease goes undetected until the time of the first heart attack, and
this first heart attack is often fatal. Modern methods of treatment have
improved greatly the outlook for patients having heart attacks, but major
progress in our battle against this number one killer must rest on finding
preventive measures. A number of risk factors have been
identified as strongly associated with coronary heart disease. Cigarette
smoking, high blood pressure, and high blood cholesterol are the most
clearly established of these factors. Risk is greater in men, increases
with age, and has a strong genetic component. Obesity, diabetes mellitus,
physical inactivity, and behavior pattern are also risk factors. A large body of evidence of many kinds
links elevated blood cholesterol levels to coronary heart disease.
However, some doubt remains about the strength of the evidence for a
cause-and-effect relationship. Questions remain regarding the exact
relationship between blood cholesterol and heart attacks and the steps
that should be taken to diagnose and treat elevated blood cholesterol
levels. To resolve some of these questions, the
National Heart, Lung, and Blood Institute and the NIH Office of Medical
Applications of Research convened a Elevated blood cholesterol level is a major
cause of coronary artery disease. It has been established beyond a
reasonable doubt that lowering definitely elevated blood cholesterol
levels (specifically blood levels of low-density lipoprotein cholesterol)
will reduce the risk of heart attacks due to coronary heart disease. This
has been demonstrated most conclusively in men with elevated blood
cholesterol levels, but much evidence justifies the conclusion that
similar protection will be afforded in women with elevated levels. After
careful review of genetic, experimental, epidemiologic, and clinical trial
evidence, we recommend treatment of individuals with blood cholesterol
levels above the 75th percentile (upper 25 percent of values). Further, we
are persuaded that the blood cholesterol level of most Americans is
undesirably high, in large part because of our high dietary intake of
calories, saturated fat, and cholesterol. In countries with diets lower in
these constituents, blood cholesterol levels are lower, and coronary heart
disease is less common. There is no doubt that appropriate changes in our
diet will reduce blood cholesterol levels. Epidemiologic data and over a
dozen clinical trials allow us to predict with reasonable assurance that
such a measure will afford significant protection against coronary heart
disease. For these reasons we recommend that:
These dietary recommendations are similar
to those of the American Heart Association and the Inter-Society
Commission for Heart Disease Resources. We further recommend that:
The evidence supporting a causal
relationship between blood cholesterol levels and coronary heart disease
comes from a wealth of congruent results of genetic, experimental
pathologic, epidemiologic, and intervention studies. These data establish
beyond any reasonable doubt the close relationship between elevated blood
cholesterol levels (as measured in serum or plasma) and coronary heart
disease. At the same time, it is equally clear that an elevated blood
cholesterol level is not the only cause of coronary heart disease.
Hypertension, cigarette smoking, diabetes mellitus, obesity, and physical
inactivity along with a number of other risk factors such as age, sex, and
family history are important contributing causes. There probably are other
undiscovered contributing causes. However, we shall confine ourselves here
primarily to a discussion of elevated blood cholesterol. It is now firmly established that all
cholesterol is carried in the bloodstream in several protein-lipid
combinations known as lipoproteins and that most of the blood cholesterol
in humans is carried by specific low-density lipoproteins (LDL). Some is
also present in high-density lipoproteins (HDL) and in very low-density
lipoproteins (VLDL). The LDL particles, when present in excess in the
blood, are deposited in the tissues and form a major part of a buildup in
the artery wall to form atherosclerotic plaque. Atherosclerosis narrows
the channels of the coronary arteries, the vessels that furnish the major
blood supply to the heart muscle. Severe coronary heart disease can result
from high blood cholesterol levels in the absence of any other
contributing risk factors. This is clearly demonstrated by the accelerated
and clinically catastrophic coronary heart disease in children with
inherited hypercholesterolemia in its most severe form. These children
lack the specific receptor that normally removes LDL from the blood, and
as a result, they have very high LDL cholesterol levels from birth. They
frequently suffer severe coronary heart disease, and death may occur even
in childhood. Careful study of these diseased arteries reveals large
quantities of cholesterol in the plaques. The LDL receptor normally plays a critical
role in regulating blood cholesterol levels in all mammals, including
humans. It has been purified and fully characterized. Studies suggest that a number of cases of
clinically important coronary heart disease with less severe elevations of
blood cholesterol may be explained by partial deficiencies of functioning
LDL receptors, deficiencies induced by dietary and lifestyle factors.
Thus, the high blood cholesterol in these patients has a similar basis to
that in inherited hypercholesterolemia and, while less severe, probably
has the same implications. With improved use of the many existing
animal models, a number of very important relationships between blood
cholesterol, atherosclerosis, and coronary heart disease have been
demonstrated:
Animal studies thus offer strong and
persuasive evidence supporting the causal relationship between blood
cholesterol and atherosclerosis. A large body of epidemiologic evidence
supports the direct relationship between blood cholesterol levels and
coronary heart disease:
Thus, the evidence obtained from genetic,
experimental, epidemiologic, and clinical intervention investigations
overwhelmingly supports a causal relationship between blood cholesterol
levels and coronary heart disease. Our conclusion that reduction of blood
cholesterol levels First, metabolic ward studies establish
beyond reasonable doubt three dietary maneuvers that lower blood
cholesterol levels: reducing the saturated fat content, increasing the
polyunsaturated fat content, and reducing the cholesterol content. Second,
a number of drugs have been developed that lower blood cholesterol levels.
The issue of whether these interventions also influence coronary heart
disease events has been more challenging. In previous years, more than a dozen
randomized trials of the effects of fat-controlled diets or drugs have
been reported. Most showed some decrease in coronary heart disease event
rates in the treated group, and the dietary trials carried out by Dayton
et al. and by Leren et al. were particularly suggestive, producing 23
percent and 35 percent reductions in the incidence of coronary heart
disease. However, no study considered individually could be regarded as
conclusive: the sample sizes were too small, and there were in some cases
unanticipated increases in non-cardiovascular deaths, although these were
not statistically significant. An aggregate analysis of all unifactor
blood-cholesterol-lowering trials, while not revealing an effect on total
mortality, does indicate that coronary heart disease rates can be reduced
by reduction of blood cholesterol levels. These findings have been extended by two
recently reported randomized and blinded clinical trials of the efficacy
of the cholesterol-lowering drug, cholestyramine. One of these studies,
the Lipid Research Clinics Coronary Primary Prevention Trial, showed a
statistically significant 19 percent reduction in the combined rate of
fatal and nonfatal coronary heart disease in association with a 9 percent
decrease in blood cholesterol level. The other study, the NHLBI Type II
Coronary Intervention Study, showed a reduction in the angiographic
progression of coronary artery disease. In addition, a third trial (the
Coronary Drug Project) has recently presented information extending the
earlier published finding that the use of nicotinic acid lowers the rate
of recurrent coronary heart disease by demonstrating in long-term followup
a decrease in overall mortality. These findings, taken in conjunction with
the results of the earlier studies, permit the conclusion that reduction
of blood cholesterol level in people with relatively high initial levels
will reduce the rate of coronary heart disease. The clinical trials are
too limited to settle the issue of effects on overall mortality. However,
the complete set of evidence, which includes information derived from
animal, pathophysiological, metabolic, and epidemiologic studies, makes it
reasonable to presume that the reduction in coronary heart disease
incidence will be accompanied by a reduction in overall mortality. The magnitude of the reduction in coronary
heart disease risk can be estimated from these clinical trials; they
indicate that each 1 percent reduction in blood cholesterol level yields
approximately a 2 percent reduction in coronary heart disease rates. This
is remarkably similar to the magnitude of the beneficial outcome predicted
from observational epidemiologic studies. Thus, for example, a 5 percent
reduction in blood cholesterol level resulting from the diets recommended
below should reduce coronary heart disease rates by 10 percent. The
absolute magnitude of this benefit should be greater in patients at high
risk because of existing coronary heart disease or the presence of other
risk factors such as cigarette smoking and hypertension. Reductions in
disease rates of as much as 50 percent may be achievable in high-risk
cholesterol patients who adhere well to a combination of effective drug
treatment and a fat-controlled diet. A precise definition of
hypercholesterolemia (an abnormally high blood cholesterol level) is
difficult to establish. Often, an abnormally high level of a biologic
substance is considered to be that level above which are found the upper 5
percent of the population (the 95th percentile). However, the use of this
criterion in defining "normal" values for blood cholesterol
levels in the United States is unreasonable; coronary heart disease is our
major cause of death and, in part at least, because a large fraction of
our population probably has too high a blood cholesterol level. A review
of available data suggests that levels above 200 and 230 mg/dl are
associated with an increased risk of developing premature coronary heart
disease. It is staggering to realize that this represents about 50 percent
of the adult population of the United States. The consensus panel has
chosen to define two levels of hypercholesterolemia, both of which are
associated with an increased coronary heart disease risk, and both of
which should be treated. This category is defined as values at
approximately the 90th percentile or above as determined by the Lipid
Research Clinics Prevalence Study (see
Table 1 for guidelines). It will include individuals with hereditary
forms of high blood cholesterol and will require the most aggressive
treatment. Withholding treatment subjects these individuals to unnecessary
risk. This category is defined as values
approximately between the 75th to 90th percentiles (see
Table 1 for guidelines). It includes large numbers of people whose
elevated blood cholesterol is due, in part, to their diet. The intensity
of treatment is guided by the clinical and family history and the presence
of other risk factors predisposing to coronary heart disease. The presence of high-risk and moderate-risk
blood cholesterol should be confirmed by a repeat analysis. Although the
initial sample may be obtained nonfasting, the repeat analysis should be
obtained after an overnight fast so that a valid triglyceride level also
can be determined. After the secondary causes for
hypercholesterolemia (e.g., hypothyroidism, nephrotic syndrome,
dysproteinemias, diabetes mellitus, and obstructive liver disease) have
been excluded, the primary cause should be evaluated. This includes family
screening to detect the hereditary forms of elevated blood cholesterol and
to identify other family members needing treatment. Measurement of HDL
cholesterol is often helpful to determine if the elevated blood
cholesterol is due to high levels of HDL (which is associated with a lower
risk of coronary heart disease). In addition, a low HDL cholesterol (an
independent risk factor) might guide a physician to be more aggressive in
treatment of individuals with high or moderately high blood cholesterol. The first step in the treatment of
high-risk and moderate-risk blood cholesterol is diet therapy and caloric
restriction for weight normalization in the overweight. Weight loss may
reduce blood cholesterol, and a moderate level of physical exercise may be
helpful in this regard. The dietary approach should be to lower total fat,
saturated fat, and cholesterol consumption. The following guidelines are
generally consistent with those of the American Heart Association and the
Atherosclerosis Study Group of the Inter-Society Commission for Heart
Disease Resources. We recommend a diet composed of approximately 30
percent of the caloric intake from fats and no more than 250 to 300 mg of
cholesterol a day. An essential consideration is a reduction of the total
saturated fat intake to 10 percent or less of total calories. It is
recommended that polyunsaturated fat intake be increased but to no more
than 10 percent of total calories. These changes can be readily made while
maintaining intake of protein, vitamins, and minerals to satisfy the
Recommended Dietary Allowances of the Food and Nutrition Board of the
National Research Council. Insufficient response to this diet may
necessitate further restrictions of total fat to 20 to 25 percent of
calories with saturated fat comprising 6 to 8 percent of the calories. The
dietary cholesterol should be lowered to 150 to 200 mg/day (equivalent to
American Heart Association Phases II and III diets). The use of diet as a primary mode of
therapy requires a major effort on the part of physicians, nutritionists,
dietitians, and other health professionals. Lifestyle changes are
difficult without adequate instruction, motivation, and encouragement.
Education of physicians, as well as the general public, as to the value of
reductions in dietary saturated fat and cholesterol will assist not only
with treatment of patients with high- or moderate-risk blood cholesterol
but also in achieving the goal of reducing the blood cholesterol levels of
our entire adult population to less than 200 mg/dl (less than 180 mg/dl in
those under age 30). Drug therapy should be used only after a
careful trial of diet modification using the most rigorous diet
appropriate for the particular individual. Even when drugs seem
appropriate, it is important to stress that maximal diet therapy should be
continued. Several drugs, used singly or in combination, are now
available. These include the bile-acid sequestrants (cholestyramine and
colestipol), nicotinic acid, probucol, and the fibric acids (clofibrate
and gemfibrozil). Of these, bile-acid sequestrants and nicotinic acid have
been shown to reduce coronary heart disease. Clofibrate, while effective
in treating one rare familial form of lipid abnormality (Type III
hyperlipoproteinemia), is not recommended because it is not effective in
most individuals with a high blood cholesterol level but normal
triglyceride level. Moreover, an excess overall mortality was reported in
the World Health Organization trial of this drug. We still do not have
direct evidence for the safety of any cholesterol-lowering drugs when
given over decades; therefore, drug treatment should be undertaken
cautiously and its desirability should be periodically reevaluated,
particularly in children. Individuals with high-risk blood
cholesterol (severe hypercholesterolemia), especially those with the
hereditary form, may well require drug therapy in addition to dietary
modification. Combined drug treatment (e.g., bile-acid sequestrant plus
nicotinic acid) may be particularly effective. Several combined treatment
regimens are under study. Individuals with moderate-risk blood cholesterol
will usually respond adequately to diet alone. Judgment on the decision to
use drugs in such patients must be made on a case-by-case basis, taking
into account family history of coronary heart disease, existing coronary
disease in the individual, coexistence of other risk factors, and age of
the individual. As described above, individuals with high-
and moderate-risk cholesterol levels (greater than the 75th percentile)
should be treated with diet or diet and drugs. Furthermore, it is clearly
recognized that it is a goal to encourage reduction of the blood
cholesterol to approximately 180 mg/dl for adults under the age of 30
years and to approximately 200 mg/dl for individuals age 30 or older. This
is recognized as a realistic "target" level that should be
possible to achieve and that would be predicted to have a beneficial
effect on coronary heart disease risk. As will be discussed in the
following section, it is recommended that all individuals in the
population consume a diet composed of approximately 30 percent of the
calories as fat (10 percent or less saturated fat) and 250 to 300 mg of
cholesterol a day in an attempt to shift the blood cholesterol levels in
our population toward the lower levels observed in populations having much
lower rates of coronary heart disease. Both men and women at high risk, as defined
above, should be treated similarly, even though premenopausal women have
an apparent protection, and the onset of the disease occurs later than in
men. However, as in men, the leading cause of death in women is coronary
heart disease, and blood cholesterol is a risk factor. Despite the fact
that direct intervention studies have not been conducted in women, there
is no reason to propose a separate treatment schedule for women. Studies are available that indicate a
beneficial effect of treating high cholesterol levels in individuals with
preexisting clinical disease (secondary intervention) as well as in
individuals without preexisting clinical disease (primary intervention).
Because of their vulnerability, patients with established disease,
including particularly patients with coronary bypass grafts, should be
intensively treated. It is encouraging that the progression of established
lesions may be retarded by appropriate dietary and drug therapy. The same
may apply to the elderly patient. While there is no direct evidence on the
benefit to be expected in the elderly, and while blood cholesterol becomes
less important as a risk factor in old age, dietary treatment (with due
attention to ensure nutritional adequacy) may still be helpful. Identifying and treating children with
elevated blood cholesterol levels is a subject for special consideration.
It is desirable to begin prevention in childhood because patterns of
lifestyle are developed in childhood. The moderate-fat and
moderate-cholesterol diets recommended for the population at large in this
report should be suitable for all family members, including healthy
children over the age of 2 years. For children, the diets should provide
all nutrients in quantities adequate to assure growth and development and
meet energy requirements. Excessive gain in weight should be avoided. The
diet may be inappropriate in children or in the elderly if they are
malnourished or have special nutritional requirements. For others, the
diet plan is safe and nutritionally adequate. Children at "high-risk" should be
identified primarily by carefully obtained family histories rather than
routine screening. The history should include parents, grandparents, and
all first-degree relatives. A family history of hypercholesterolemia or
premature coronary heart disease should alert the physician to obtain at
least two blood cholesterol determinations. If the blood cholesterol level
in such "high-risk" children is above the 75th percentile
(approximately 170 mg/dl for ages 2 to 19 years), total and HDL
cholesterol should be obtained. Those children with blood cholesterol
levels between the 75th and 90th percentile (170 to 185 mg/dl) should be
counseled regarding diet and other cardiovascular risk factors and then
followed at 1-year intervals. Those with levels above the 90th percentile
(over 185 mg/dl) require special dietary instruction and close supervision
with evaluation of other risk factors. A child with a blood cholesterol
level above the 95th percentile (greater than 200 mg/dl) on two occasions
is in a special category and may have one of the hereditary
hypercholesterolemias. Strict dietary intervention is indicated and will
be sufficient for many children. Nonresponders should be considered for
treatment with a lipid-lowering agent, e.g., bile-acid sequestrant (such
as cholestyramine). All family members should be screened. Dietary management of children with
elevated blood cholesterol levels should be part of total management that
includes regular exercise programs, maintenance of ideal weight, avoidance
of excess salt and avoidance of cigarette smoking. According to data from the National Center
for Health Statistics, a high percentage of the American population sees a
physician at least once every year. If a cholesterol level were determined
on adults at these visits, many of the individuals with cholesterol levels
above the 75th percentile would be identified in a relatively short time
and should be evaluated and treated as described above. This physician-
and clinic-oriented method for screening would be cost-effective.
Obviously, some patients may not see a physician for several years, and it
would be advisable to educate the public to the importance of knowing
one's cholesterol level. In children, only a "family history
screening" is recommended, that is, cholesterol levels should be
obtained in those at higher risk because of a strong family history, as
discussed above. Educational programs developed by voluntary and public
health organizations in conjunction with the National Cholesterol
Education Program of the National Heart, Lung, and Blood Institute, as
recommended by this consensus panel, should alert all adults to the
advisability of learning their cholesterol level. While we are not at this time recommending
mass screening, a feasibility study of various screening methods in adults
should be considered. Screening necessitates the availability of
laboratories capable of determining precisely and accurately the blood
cholesterol and HDL cholesterol levels and of physicians willing and able
to manage large numbers of new patients. Thus, preliminary steps are
needed before mass screening can be considered. Many compelling lines of evidence link
blood cholesterol to coronary heart disease. There is also good evidence
from epidemiologic studies that the relationship between level of
cholesterol and level of risk for coronary heart disease covers virtually
the entire cholesterol distribution for the U.S. population. In fact,
recent epidemiologic studies suggest that the relationship holds even at
the lower end of the spectrum of cholesterol levels found in our
population. The Japanese population, in comparison with
the U.S. population, is characterized by a much lower average cholesterol
level and a much lower frequency of coronary heart disease. The Finnish,
on the other hand, have a much higher average cholesterol level and a much
greater risk of coronary heart disease than do U.S. citizens. Furthermore,
Japanese who have migrated to Hawaii and to San Francisco have higher
cholesterol levels and a higher risk of coronary heart disease than
nonmigrants. Compilation of all the available data suggests that it will
be beneficial to lower the blood cholesterol of the average American. In recent years, Americans have been
changing their habitual diet in the direction we recommend, that is, by
reducing their intake of total fat, saturated fat, and cholesterol and by
increasing intake of polyunsaturated fat. This has been accompanied by a
substantial reduction in the average blood cholesterol of the population.
In addition, all-cause mortality, cardiovascular mortality, and coronary
heart disease mortality have also decreased, but it is difficult to
determine with certainty how much, if any, of this decrease is due to
changes in diet, blood pressure, cigarette usage, or improved medical
care. It is hoped that improved surveillance systems will clarify these
issues. In the general population, the basic
intervention should be based on diet rather than drugs. We recommend a
shift from the current typical American diet to one that is lower in total
fat, saturated fat, and cholesterol. Diets with these characteristics are
the usual diets consumed in a number of other countries, e.g., Japan and
Greece. Life expectancy in these two countries is, at virtually every age,
greater than that in the United States. This applies also to the life
expectancy in middle age, when mortality from coronary heart disease
begins to rise sharply. The evidence justifies for men, women, and
children ages 2 years and older the reduction of calories from fat from
the present average level of 40 percent to 30 percent, calories from
saturated fat to 10 percent or less, and dietary cholesterol to no more
than 250 to 300 mg daily. We recommend that calories from polyunsaturated
fat be increased, but not exceed 10 percent of total calories. This diet
is generally consistent with the most recent recommendations of the
American Heart Association and the Atherosclerosis Study Group of the
Inter-Society Commission on Heart Disease Resources. Equally important,
individuals, health professionals, and health agencies must recognize the
need to control obesity both to aid in controlling blood cholesterol
levels and to reduce the other health risks of obesity. Other elements
important to the prevention of cardiovascular disease, including avoidance
of cigarettes, control of high blood pressure, and maintenance of
reasonable levels of physical activity are recommended.
We know that blood cholesterol is causally
related to coronary heart disease and that the atherosclerotic process can
be influenced by intervention. However, much about lipid metabolism and
about the mechanisms of the atherosclerotic process remains unknown.
Since the NIH Consensus Statement on
Lowering Blood Cholesterol to Prevent Heart Disease was issued, additional
information has become available that supplements the original statement. Recommendations included in the statement
continue to provide overall guidance for activities realted to the role of
cholesterol in heart disease. In response to a key recommendation in the
consensus statement, a National Cholesterol Education Program (NCEP) was
established by the National Heart, Lung, and Blood Institute (NHLBI) to
foster professional and public education concerning the significance and
proper management of elevated blood cholesterol. Listed below are several
other areas of emphasis in the statement that have subsequently been
amplified by new findings or modified through NCEP activities. Comment: Since the time of the
conference, several clinical trials reported results that provide
further support for the conclusions reached by the panel. Evidence has
especially accumulated in the area of secondary prevention of CHD,
including many trials that used angiographic endpoints.
These new data provided additional
rationale for the NCEP The benefits of cholesterol-lowering have
been strongly confirmed and extended through the findings of three
recently reported large clinical trials each of which used a drug
belonging to the statin class, which is very effective in lowering total
and low density lipoprotein-cholesterol. These trials observed that
20-30 percent reductions in serum cholesterol levels in patients without
evident coromary heart disease (primary prevention trials) or in
patients with clinical disease (secondary prevention trials) reduced
fatal and non-fatal heart attacks by 30-40 percent. Similar reductions
occurred in bypass surgery and angioplasty. Mortality from non-coronary
causes was unchanged, so that overall mortality was reduced. There were
virtually no serious side effects. Other trials have shown statin
treatment to slow the progression of the fatty plaques in the coronary
arteries.
Comment: The Consensus Panel
recommendations concerning adults with hypercholesterolemia have been
superseded by the NCEP Guidelines included in the Second
Report of the Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults, which was issued in June 1993.
This document provides a more detailed strategy for individual
management of adults with hypercholesterolemia. The Consensus Panel
recommendations for individual management of hypercholesterolemia in
high-risk children and adolescents have also been superseded. Current
guidance on this issue may be found in the NCEP Report of the Expert
Panel on Blood Cholesterol Levels in Children and Adolescents,
available from the NHLBI
Information Center.
Comment: An NCEP expert panel
report has also superseded the consensus statement recommendations to
the general public concerning efforts to reduce blood cholesterol. The Report
of the Expert Panel on Popluation Strategies for Blood Cholesterol
Reduction, which was issued in November 1990, specifically addresses
the issue. This publication is available from the NHLBI
Information Center.
Comment: The 1992 NIH
Consensus Statement on Triglyceride, High Density Lipoprotein, and
Coronary Heart Disease complements the 1984 consensus statement. Its
recommendations contributed to the NCEP Second
Report of the Expert Panel on Detection, Evaluation, and Treatment of
High Blood Cholesterol in Adults. |
||||||||||||
