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the osteopathic physician. The treatment
approach involves therapeutic lifestyle
changes with diet, exercise, and weight
loss. It requires regular, careful monitoring of serum cholesterol levels. The
new ATP III guidelines expand greatly
the total number of patients who are eligible for treatment of hypercholesterolemia. Definite goals for LDL-C are
defined for patients with coronary heart
disease and patients at risk for subsequent clinical events. Many, if not most
of these patients, will not be able to
achieve their target LDL-C level without
pharmacologic therapy.
The ATP III evidence-based guidelines have defined the standard. It is our
responsibility and unique opportunity
to fulfill these expectations through
thoughtful clinical practice. We might
consider this supplement to represent a
tool to help us accomplish this task.
References
1. Expert Panel on the Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults.
Executive Summary of the Third Report of the
National Cholesterol Education Program (NCEP)
Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III). JAMA. 2001;285:2486-2497.
2. The American Heart Association 2002 Heart
and Stroke Statistical Update. Dallas, Tex: American
Heart Association; 2001; pp 4-23.
3. Pearson TA, Laurora I, Chu H, Kafonek S. The
Lipid Treatment Assessment Project (L-TAP): A
multicenter survey to evaluate the percentages
of dyslipidemic patients receiving lipid-lowering
therapy and achieving low-density lipoprotein
cholesterol goals. Arch Intern Med. 2000;160:459467.
4. Stafford RS, Blumenthal D, Pasternak RC. Variations in cholesterol management practices of US
physicians. J Am Coll Cardiol. 1997;29:139-146.
5. Bramlett DA, King H, Young L, Witt JR,
Stoukides CA, Kaul AF. Management of hypercholesterolemia: practice patterns for primary care
providers and cardiologists. Am J Cardiol.
1997;80:39H-44H.
Dr Rogers, a practicing cardiologist, is a clinical
professor in the Department of Internal Medicine
at the Michigan State University College of Osteopathic Medicine in East Lansing.
E-mail: [email protected]
This educational program was developed from
information presented during a scientific symposium conducted on October 11, 2002, in Las
Vegas, Nevada, at the 2002 Annual Convention
and Scientific Seminar of the American Osteopathic Association.
The National Cholesterol Education
Program Adult Treatment Panel III
guidelines
Michael B. Clearfield, DO
Coronary heart disease (CHD) remains the leading cause of death in the United
States with more than 40% of all deaths each year directly attributed to the
disease. Current evidence suggests that early identification and aggressive
modification of risk factors offer the most promising approach to reducing
the burden of CHD. Dyslipidemia has been identified as the primary risk
factor leading to the development of CHD. It is estimated that nearly 65 million Americans require some form of lipid-modification therapy.
The National Cholesterol Education Program Adult Treatment Panel III
(NCEP ATP III) set of guidelines released in May 2001 provides physicians with
evidence-based recommendations on the classification, diagnosis, and treatment
of lipid disorders. New features of the guidelines include a scoring system
for calculating CHD risk, as well as the identification of CHD risk equivalents, lower treatment target goals, and an emphasis on conditions conferring
a higher risk for CHD, such as the metabolic syndrome. The ATP III emphasis
on risk assessment substantially increases the number of patients considered
at risk for CHD and will expand the number eligible for lifestyle and drug interventions.
This article highlights the new recommendations and reviews the impact
of ATP III on osteopathic physicians.
(Key words: atherosclerosis, cholesterol, coronary heart disease, dyslipidemia, low-density lipoprotein cholesterol [LDL-C])
C
oronary heart disease (CHD) has
persisted as the single leading cause
of death among Americans. According
to the American Heart Association,1
more than 1.1 million new or recurrent
myocardial infarctions occurred in 2000
and more than 500,000 Americans died
of CHD-related causes. Coronary heart
disease also places a significant financial burden on the US economy with
direct and indirect costs of the disease
estimated to be nearly $330 billion in
2002.1
Dyslipidemia is recognized as a
major modifiable risk factor for the development and progression of CHD.
Numerous clinical trials have demonstrated that CHD-related morbidity and
mortality is reduced after aggressive
intervention that includes both lifestyle
Dr Clearfield is a professor of medicine and associate dean for clinical research at the University of
North Texas Health Science Center at Fort Worth/Texas College of Osteopathic Medicine. Dr Clearfield
represented the American Osteopatic Association, a member organization of the National Cholesterol
Education Program Coordinating Committee, which approved the Third Report of the National Cholesterol Education Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.
Dr Clearfield is a member of the speakers bureau of AstraZeneca, Merck & Co, Pfizer Inc, and
Sankyo Pharma Inc, and he has received grant/research support from AstraZeneca and Pfizer Inc.
Correspondence to Michael B. Clearfield, DO, Associate Dean for Clinical Research, Office of the Dean,
Texas College of Osteopathic Medicine, University of North Texas Health Science Center at Fort Worth,
855 Montgomery St, Fort Worth, TX 76107-2699.
E-mail: [email protected]
Clearfield • The National Cholesterol Education Program Adult Treatment Panel III guidelines
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JAOA • Supplement 1 • Vol 103 • No 1 • January 2003 • S1
modifications and pharmacologic
therapy.2-5 In May 2001, the Adult Treatment Panel (ATP) of the National Cholesterol Education Program (NCEP) issued
its third set of guidelines (NCEP ATP III)
for the identification and management
of dyslipidemia.6 Building on ATP I
(1988) and ATP II (1993), ATP III pays
increased attention to the identification
and quantification of risk factors for CHD
and therefore vastly expands the number
of Americans eligible for lipid-lowering
therapy.
With these changes, ATP III presents
a challenge to physicians and the healthcare system to identify at-risk patients,
implement effective therapy, and ensure
that patients meet target goals (Figure 1).
Osteopathic physicians, many of whom
focus on primary care with an emphasis
on treating the entire patient, are in the
vanguard for the reduction of CHD risk.
Therefore, osteopathic physicians are
uniquely positioned to have an impact on
the implementation of the new guidelines.
New features of the
ATP III guidelines
Consistent with previous editions, the
new ATP guidelines provide an evidence-based approach for the detection
and treatment of lipid disorders. Adult
Treatment Panel III follows ATP II by
continuing to focus on reduction of lowdensity lipoprotein cholesterol (LDL-C)
as the primary goal of therapy and advocates that the intensity of therapy be
adjusted to the degree of risk. The ATP III
set of guidelines also reiterates the importance of lifestyle changes such as weight
loss, dietary modifications, and increased
physical activity in reducing CHD risk
(Figure 1).
New features of the guidelines
include the use of a risk assessment tool
based on data derived from the Framingham Heart Study,7 the identification
of diabetes (with or without clinically
evident CHD) as a CHD risk equivalent,
more aggressive lipid target levels, and
the recognition that patients with the
metabolic syndrome should be provided
intensified lipid-modification therapy
(Figure 1).
Adult Treatment Panel III places
patients into one of three categories of
Checklist
Challenges
Identify patients at risk for CHD
Implement effective therapy
Ensure that patients meet target
goals
Emphasis
Risk assessment
Reduction of low-density
lipoprotein cholesterol (LDL-C) as
primary goal of therapy
Adjustment of intensity of therapy
to degree of risk
Importance of lifestyle changes to
include:
— weight loss
— dietary modifications
— increased physical activity
New features
Use of a risk assessment tool based
on data derived from the
Framingham Heart Study
Identification of diabetes as a
coronary heart disease (CHD) risk
equivalent
More aggressive lipid target goals
Intensified lipid-modification
therapy for patients with the
metabolic syndrome
Raising target for high-density
lipoprotein cholesterol level (to
40 mg/dL)
Lowering target for triglyceride
concentration (to 200 mg/dL)
Strategies for promoting adherence
to treatment regimens
Figure 1. Challenges, emphasis, and new
features of the Adult Treatment Panel III
guidelines.
CHD risk (high, moderate, low) and
identifies specific LDL-C treatment goals
for each (Figure 2). The LDL-C target
levels for patients with CHD and CHD
risk equivalents (highest risk) are now
less than 100 mg/dL. For patients with
two or more risk factors (moderate risk),
the target level is less than 130 mg/dL,
and for patients with zero or one risk
factor (low risk), the goal is less than
160 mg/dL.
Adult Treatment Panel III also recognizes the role high-density lipoprotein
cholesterol (HDL-C) and triglycerides
play in modifying CHD risk and therefore raised the target level for HDL-C
from less than 35 mg/dL to less than
40 mg/dL and lowered target goals for
S2 • JAOA • Supplement 1 • Vol 103 • No 1 • January 2003
triglycerides to less than or equal
to 200 mg/dL.
Further, ATP III recognizes that the
heightened emphasis on risk assessment,
the inclusion of CHD risk equivalents,
and the more aggressive treatment goals
will significantly increase the number of
patients eligible for therapy and challenge physicians and the healthcare
delivery system to implement the guidelines. Therefore, ATP III also presents
strategies for promoting adherence
totherapeutic lifestyle changes (TLC) and
drug therapy.
Assessment of risk for
coronary heart disease
The Framingham risk scoring system
incorporated into ATP III quantifies the
10-year risk for a coronary event. Point
scores are calculated according to the
presence of five major CHD risk factors
(age and gender, total cholesterol, systolic blood pressure, HDL-C level, and
smoking status), with each risk factor
worth a certain number of points. When
added together, the sum yields an estimate of the risk for having a coronary
event in 10 years. A properly conducted
assessment places patients into one of the
three risk categories and forms the basis
for all subsequent treatment decisions.
Patients with documented CHD and
CHD risk equivalents are automatically
placed in the highest risk category. The
CHD risk equivalents carry a risk for a
major coronary event equal to that of
established CHD and include diabetes,
peripheral vascular disease, symptomatic
carotid artery disease, and abdominal
aortic aneurysm. The new set of guidelines places patients with these conditions in the same risk category as those
with clinically evident CHD (eg, 20%
10-year risk of CHD). The LDL-C treatment goal for patients in this high-risk
category is less than 100 mg/dL.
In patients without documented
CHD or CHD equivalents, assessment
of CHD risk using the Framingham risk
quantification system is essential to determine the most appropriate course of
therapy. Patients with two or more major
risk factors are considered to be at a moderately increased risk for CHD, with a
10-year risk of less than 20%. Therapy
for the patients in this category should be
Clearfield • The National Cholesterol Education Program Adult Treatment Panel III guidelines
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uptake. Physical activity raises HDL-C
levels and decreases the concentration of
very low-density lipoprotein cholesterol
and triglycerides. Smoking cessation also
results in a reduction of CHD risk.
Adult Treatment Panel III
Pharmacologic therapy
Risk stratification
Treatment goal level
(low-density lipoprotein
cholesterol)
High risk of coronary heart
disease (CHD)
(documented CHD or CHD
risk equivalent)
100 mg/dL
Moderate (two or more risk
factors)
130 mg/dL
Low (zero to one risk factor)
160 mg/dL
Figure 2. Low-density lipoprotein cholesterol goals according to risk factor stratification.
(Source: Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment Panel III) Full Report. Available at: http://www.nhlbi.
nih.gov/guidelines/cholesterol/atp3_rpt.htm. Accessed December 2, 2002.)
sufficient to enable them to achieve an
LDL-C target level of less than
130 mg/dL. Patients at the lowest risk
are those with one or fewer major risk
factors. In all but rare cases, these individuals have a 10-year risk of less than
10%. The target LDL-C level in this group
of patients is less than 160 mg/dL.
Current treatment trends
With the increased emphasis on risk
assessment and aggressive new treatment
goals, it is estimated that the number of
patients eligible for CHD risk reduction
through lipid-modification therapy in the
United States is currently at 65 million.
The type and extent of therapy is dependent on the patient’s CHD risk. Two primary modalities advocated by ATP III
for lowering LDL-C, and therefore CHD
risk, are ATP TLC and drug therapy.
Therapeutic lifestyle changes
First-line therapy for all patients is TLC
and may be substantial enough in groups
at lower risk to reach their LDL-C goals.
Components of TLC that have demonstrated effectiveness in lowering LDL-C
include eating a healthy diet, regular
physical activity, smoking cessation, and
weight loss. Dietary changes should
include a reduction of saturated fats to
less than 7% of total calories, reduction of
intake of dietary cholesterol to less than
200 mg/d, addition of plant sterols and
stanols at a level of 2 g/d (commercially
available in special margarines), and
incorporating viscous fiber into the diet at
a level of 10 g/d to 25 g/d. Weight reduction can reduce LDL-C levels and ameliorate the risk factors associated with the
metabolic syndrome by improving
insulin sensitivity and serum glucose
Clearfield • The National Cholesterol Education Program Adult Treatment Panel III guidelines
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Although ATP III emphasizes the importance of nonpharmacologic therapy, it
recognizes limitations of such therapy
and encourages the addition of drug
therapy if TLC fails to move a patient to
goal after 3 months. High-risk patients
will most likely require drug therapy
along with TLC from the onset of treatment. As stated earlier, treatment goals
and lipid thresholds for initiating drug
therapy are based on the patient’s degree
of risk.
For patients with the highest risk for
coronary events, the LDL-C threshold
for initiation of therapy is greater than
or equal to 130 mg/dL (after a 3-month
trial of TLC) and the goal is less than
100 mg/dL. For patients with LDL-C
between 100 mg/dL and 129 mg/dL,
drug therapy is optional and physicians
are encouraged to use their professional
clinical judgment to determine the nature
of therapy required to reduce CHD risk.
For patients with moderate risk
without definite CHD or CHD risk
equivalents but with more than two
major risk factors and a 10-year risk of
10% to 20%, the threshold is greater than
or equal to 130 mg/dL and the target is
also less than 130 mg/dL.
For patients at moderate risk but with
a 10-year risk of less than 10%, the
threshold for LDL-C is greater than or
equal to 160 mg/dL and the target is less
than 130 mg/dL. For patients without
CHD and with zero to one major risk
factor, drug treatment should be considered if the LDL-C cholesterol level is
greater than or equal to 190 mg/dL after
3 months of TLC, with a goal of greater
than or equal to 160 mg/dL. In all cases
of drug therapy, TLC should continue
to be maintained and reinforced.
Currently available
lipid-modifying drugs
Four classes of lipid-modifying drugs
are currently available in prescription
form, including bile acid sequestrants,
nicotinic acids, fibric acid derivatives,
JAOA • Supplement 1 • Vol 103 • No 1 • January 2003 • S3
and 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins).
Statins, the most widely used lipid-modifying agent, decrease LDL-C by
inhibiting cholesterol synthesis and
reduce LDL-C by 25% to 50% in a dosedependent manner.
The currently available statins are
differentiated by the LDL-C lowering
elicited at a given dose. Several large clinical outcomes trials have demonstrated
that statin use reduces the incidence of
CHD events, including myocardial infarction, coronary death, stroke, and total mortality.2-5 Bile acid sequestrants are another
commonly used agent.
Bile acid sequestrants can be used as
monotherapy when moderate reductions
in LDL-C are required to achieve goal or
as add-on therapy to statins, particularly
in patients with severe dyslipidemia.
A third class of agents is nicotinic
acid, or niacin. Nicotinic acids provide
a moderate LDL-C–lowering action, but
the primary utility of these agents is in
combination with statins for patients who
have elevated triglyceride concentrations
or low HDL-C levels or both.
Fibric acids, or fibrates, are a fourth
class of lipid-modifying agents that possess minimal LDL-C–reducing capacity,
but these agents are useful in patients
with combined forms of hyperlipidemia.
Fibrates are especially effective in patients
who have severe hypertriglyceridemia.
Despite the efficacy of statins in
modifying lipid levels and reducing coronary events, alternative agents are
needed. Some patients are unable to tolerate statins, or they are not candidates
for use of these agents because of either
or both tolerability and safety concerns.
In these cases, physicians and patients
are forced to use bile acid sequestrants,
niacin, fibrates, or other less common
modes of therapy. These agents, however, vary in their effectiveness in
reducing LDL-C levels owing to low efficacy of the agent or poor compliance due
to undesired side effects.
A promising new alternative mode of
therapy was recently approved by the US
Food and Drug Administration (FDA).
Phase II data suggest that ezetimibe, the
first selective inhibitor of intestinal cholesterol absorption, appears to have substantial potential for use as monotherapy
in patients at low risk for CHD who
require only a modest reduction in their
LDL-C level or for those who do not tolerate statin therapy.8 In addition, ezetimibe, when used in combination with a
low-dose statin in patients at moderate to
high risk for CHD, can elicit a reduction in
LDL-C comparable to reductions seen at
the highest statin doses.9
Implementation of the ATP III
guidelines
The ATP III set of guidelines, with an
emphasis on risk assessment and new
treatment goals, presents an enormous
challenge to physicians and the healthcare system in terms of implementation
and patient compliance. Previous guideline adherence rates indicate that
achieving the new goals will be difficult.
The ATP II guidelines, although much
less complex, were rarely followed in
patients with CHD, let alone in patients
with subclinical disease. Data from the
Lipid Treatment Assessment Project
(L-TAP)10 demonstrated that only 18%
of those with CHD achieved ATP II goals
and that less than 40% of all patients on
lipid-modification therapy receive sufficient lipid lowering to reduce CHD risk.
Because overall adherence and goal
achievement was low with previous
guidelines, the challenges inherent in
achieving ATP III goals are clear.
The ATP III acknowledges that primary prevention of CHD offers the
greatest opportunity for reducing the
clinical and economic burden of CHD in
the United States. The clinical approach
to CHD prevention begins in the primary care office and requires an
informed physician who does not focus
solely on a specific symptom and who
implements early risk screening that
includes an assessment of the overall
health of the patient. Because nearly 60%
of all osteopathic physicians practice in
primary care and account for more than
100 million primary care visits per year,
they are uniquely positioned to influence
the implementation of the ATP III guidelines. Thus, DOs can have a significant
impact on the reduction of CHD risks in
their patients.
Osteopathic physicians also treat a
large number of patients who have limited access to healthcare. Consequently,
S4 • JAOA • Supplement 1 • Vol 103 • No 1 • January 2003
DOs must educate their patients about
the importance of taking responsibility
for their own health through the incorporation of healthy lifestyle habits.
Comments
The NCEP ATP III report updates the
clinical guidelines for the detection and
treatment of lipid disorders. Although
the emphasis remains on reducing longterm CHD risk by lowering the LDL-C
level, new features of the guidelines
include a scoring system for calculating
CHD risk as well as the identification of
CHD risk equivalents. The ATP III
emphasis on risk assessment will substantially increase the number of individuals considered to be at risk for CHD
and will expand the number of patients
who will be eligible for lifestyle and drug
interventions. The new recommendations will significantly challenge physicians to screen and treat patients to more
aggressive target lipid levels.
Osteopathic physicians are uniquely
positioned to implement the new guidelines and encourage patient compliance.
References
1. American Heart Association. 2002 Heart and
Stroke Statistical Update. Dallas, Tex: American
Heart Association; 2001: pp 4, 11, 23.
2. Scandinavian Simvastatin Survival Study Group.
Randomised Trial of cholesterol lowering in 4444
patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet.
1994;344:1383-1389.
3. West of Scotland Coronary Prevention Study
Group. Influence of pravastatin and plasma lipids
on clinical events in the West of Scotland Coronary Prevention Study (WOSCOPS). Circulation.
1998;97:1440-1445.
4. Downs JR, Clearfield M, Weis S, Whitney F,
Shapiro DR, Beere PA, et al. Primary prevention
of acute coronary events with lovastatin in men and
women with average cholesterol levels: results of
AFCAPS/TexCAPS. Air Force/Texas Coronary
Atherosclerosis Prevention Study. JAMA.
1998;279:1615-1622.
5. Sacks FM, Moyé LA, Davis BR, Cole TG, Rouleau
JL, Nash DT, et al. Relationship between plasma LDL
concentrations during treatment with pravastatin
and recurrent coronary events in the Cholesterol
and Recurrent Events trial. Circulation.
1998;97:1446-1452.
6. Expert Panel on the Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults.
Executive Summary of the Third Report of the
National Cholesterol Education Program (NCEP)
Expert Panel on Detection, Evaluation and Treat-
Clearfield • The National Cholesterol Education Program Adult Treatment Panel III guidelines
Downloaded From: http://jaoa.org/pdfaccess.ashx?url=/data/journals/jaoa/932000/ on 05/02/2017
ment of High Blood Cholesterol in Adults (Adult
Treatment Panel III). JAMA. 2001;285:2486-2497.
7. Wilson PW, D’Agostino RB, Levy D, Belanger
AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97:1837-1847.
Underidentification
and undertreatment of
dyslipidemia
8. Bays H, Drehobl M, Rosenblatt S, Toth P, Dujovne
C, Knopp R, et al. Low density lipoprotein cholesterol reduction by SCH 58235 (ezetimibe), a novel
inhibitor of cholesterol absorption, in 234 hypercholesterolemic subjects: results of a dose-response
study. Atherosclerosis. 2000;151:133. Abstract.
9. Davis HR, Watkins RW, Compton DS, Cook JA,
Hoos L, Pula K, et al. The cholesterol absorption
inhibitor SCH 58235 and lovastatin synergistically
lower plasma cholesterol and inhibit the development of atherosclerosis. J Am Coll Cardiol. 2000;35(2
suppl):252A. Abstract.
10. Pearson TA, Laurora I, Chu H, Kafonek S. The
Lipid Treatment Assessment Project (L-TAP): a multicenter survey to evaluate the percentages of dyslipidemic patients receiving lipid-lowering therapy
and achieveing low-density lipoprotein cholesterol
goals. Arch Intern Med. 2000;160:459-467.
Michael B. Clearfield, DO
Despite increased attention placed on the identification and treatment of dyslipidemia, this condition remains undiagnosed and untreated in a significant
number of patients. The recently released National Cholesterol Education
Program (NCEP) Adult Treatment Panel III (ATP III) set of cholesterol management guidelines increases to more than 65 million the number of Americans eligible for lipid-modifying therapy. Recent data, however, suggest that
even with the availability of multiple regimens with proven efficacy, as many
as 50% of all patients do not have their cholesterol assessed and less than 45%
receive lipid-modifying therapy. In addition, less than 25% of patients are
treated to their NCEP target low-density lipoprotein cholesterol (LDL-C) level.
Persistence with therapy is another challenge, as more than 70% of
patients fail to maintain their therapy beyond 12 months. If a realistic attempt
is to be made to reduce the risk of coronary heart disease (CHD) among Americans, diagnosis of dyslipidemia and treatment to therapeutic targets must be
improved. This article discusses the underdiagnosis and undertreatment of lipid
disorders and reviews the role of osteopathic physicians in strategies achieving
ATP III LDL-C goals.
(Key words: Adult Treatment Panel III [ATP III], compliance, cholesterol, dyslipidemia)
L
arge numbers of patients have undiagnosed dyslipidemia, and those
who do receive a diagnosis are often
given inadequate therapy. The American Heart Association1 estimates that
more than 100 million adults in the
United States have total cholesterol
levels greater than 200 mg/dL and at
least 40% of these individuals have
cholesterol levels in excess of
240 mg/dL. The true number of dys-
lipidemic individuals in the United
States may never be known because of
the enormity of effort and magnitude
of cost required for screening all at-risk
individuals. Because more than 12.6 million Americans have coronary heart disease (CHD) and more than 500,000
deaths are attributed to this disease each
year, physicians should be strongly
encouraged to heed the advice of the
National Cholesterol Education Pro-
Dr Clearfield is a professor of medicine and associate dean for clinical research at the University of North
Texas Health Science Center at Fort Worth/Texas College of Osteopathic Medicine. Dr Clearfield represented the American Osteopatic Association, a member organization of the National Cholesterol Education Program Coordinating Committee, which approved the Third Report of the National Cholesterol
Education Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.
Dr Clearfield is a member of the speakers bureau of AstraZeneca, Merck & Co, Pfizer Inc, and
Sankyo Pharma Inc, and he has received grant/research support from AstraZeneca and Pfizer Inc.
Correspondence to Michael B. Clearfield, DO, Associate Dean for Clinical Research, Office of the Dean,
Texas College of Osteopathic Medicine, University of North Texas Health Science Center at Fort Worth,
855 Montgomery St, Fort Worth, TX 76107-2699.
E-mail: [email protected]
Clearfield • Underidentification and undertreatment of dyslipidemia
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