Therapeutic Lifestyle Changes and Drug Treatment for High Blood Cholesterol in China and Application of the Adult Treatment Panel III Guidelines

Therapeutic Lifestyle Changes and Drug Treatment for High Blood Cholesterol in China and Application of the Adult Treatment Panel III Guidelines Paul Muntner, PhD a,b,, Dongfeng Gu, MD c, Robert F. Reynolds, ScD d, Xigui Wu, MD c, Jichun Chen, MD c, Paul K. Whelton, MD a,b, and Jiang He, MD, PhD a,b The prevalence of elevated blood cholesterol in China has increased during the past several decades. We estimated the percentage of the Chinese population for whom therapeutic lifestyle changes and drug therapy to lower blood cholesterol should be considered by applying the United States National Cholesterol Education Panel s Adult Treatment Panel III guidelines to a nationally representative sample of the Chinese population from the International Collaborative Study of Cardiovascular Disease in Asia. Serum samples were collected for 14,919 Chinese adults, 35 to 74 years old, in 2000 and 2001, after an overnight fast of >8 hours and their low-density lipoprotein (LDL) cholesterol level was calculated using the Freidewald equation. Using the Adult Treatment Panel III guidelines, 85.9 million Chinese adults (18.2%) should initiate therapeutic lifestyle changes to lower their LDL cholesterol and 35.0 million (7.4%) should be considered for lifestyle changes and lipid-lowering drug therapy. Of those for whom drug therapy should be considered, 4.7 million (13.4%) reported having been told they had high cholesterol by a healthcare provider and 1.6 million (33.7% of those aware of their high cholesterol) were receiving lipidlowering medication leaving 33.4 million Chinese adults with untreated elevated LDL cholesterol (95.5% of those with elevated LDL cholesterol). A 10% populationwide reduction in LDL cholesterol would reduce the number of Chinese adults who should be considered for drug therapy by 45% to 19.3 million (4.1% of adults). In conclusion, most adults in China with an elevated LDL cholesterol remain untreated. 2005 Elsevier Inc. All rights reserved. (Am J Cardiol 2005;96: 1260 1265) The United States National Cholesterol Education Program s (NCEP) Adult Treatment Panel III (ATP-III), in tandem with an update including implications from recent clinical trials, has provided recommendations for the use of cholesterol-lowering drug therapy. 1,2 Although national guidelines for the treatment of high cholesterol for Chinese adults have not been established, in 1997, the Chinese Journal of Cardiology published an editorial report recommending low-density lipoprotein (LDL) cholesterol cutpoints at which lifestyle modification and drug therapy should be initiated. 3 The present study sought to estimate the number and percentage of Chinese adults for whom therapeutic lifestyle changes and lipid-lowering drug therapy might be appropriate using the most current NCEP a Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana; b Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana; c Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences and Peking Union Medial College, Beijing, China; and d Global Epidemiology, Pfizer Incorporated, New York, New York. Manuscript received April 4, 2005; revised manuscript received and accepted June 22, 2005. * Corresponding author: Tel: 504-988-1047; fax: 504-988-1568. E-mail address: pmuntner@tulane.edu (P. Muntner). ATP-III guidelines for the primary analyses and the Chinese Journal of Cardiology editorial board guidelines for secondary analyses. Additionally, among those for whom therapeutic lifestyle change and lipid-lowering drug therapy would be recommended, we calculated the percentage who were aware of their diagnosis of high cholesterol and the percentage who had engaged in lipid-lowering therapy. Methods Study population: The International Collaborative Study of Cardiovascular Disease in ASIA (InterASIA) was a cross-sectional study of cardiovascular disease risk factors in nationally representative samples of the general population aged 35 to 74 years in China and Thailand. It was conducted in 2000 and 2001 and has been previously described in detail. 4 In China, a total of 19,012 subjects from 20 primary sampling units (street districts in urban districts or townships in rural districts) were randomly selected and invited to participate in the survey. Of this group, 15,259 adults who were aged 35 to 74 years at the time of the survey agreed to participate in the interview, examination, and blood specimen collection procedure. We excluded 43 participants with missing high-density lipoprotein (HDL) 0002-9149/05/$ see front matter 2005 Elsevier Inc. All rights reserved. www.ajconline.org doi:10.1016/j.amjcard.2005.06.068

Preventive Cardiology/Cholesterol Treatment in China 1261 cholesterol and/or total cholesterol values and 285 participants with a triglyceride level 400 mg/dl, resulting in a final sample of 14,919 participants for the present analysis. Data collection: During the clinic visits, trained research staff administered a standardized questionnaire. Of relevance to the present analysis, participants were asked, Have you ever been told by a doctor or other health professional that your blood cholesterol level was high? Those who answered in the affirmative were considered to be aware of having a high cholesterol concentration. Participants who said yes to the questions During the past 2 weeks, did you take prescribed medicines for your high blood cholesterol? or During the past 2 weeks, have you been controlling your weight or losing weight (or exercising or eating fewer high fat or high cholesterol foods)? were considered to be taking pharmacologic drug therapy and/or following lifestyle therapeutic changes, respectively, to lower their blood cholesterol. Overnight fasting blood samples were drawn by venipuncture to measure serum total cholesterol, HDL cholesterol, and triglyceride levels. 5 Total cholesterol, HDL cholesterol, and serum triglycerides were analyzed enzymatically on a Hitachi 7060 Clinical Analyzer (Hitachi High-Technologies Corporation, Tokyo, Japan) using commercial reagents. LDL cholesterol was calculated using the Friedewald equation (LDL cholesterol total cholesterol HDL cholesterol triglycerides/5). 6 Major coronary heart disease risk factors: The ATP- III guidelines have defined major coronary heart disease (CHD) risk factors to be cigarette smoking, hypertension, HDL cholesterol 40 mg/dl, family history of premature CHD, and older age ( 45 years for men and 55 years for women). In contrast, a HDL cholesterol 60 mg/dl is considered to be a protective CHD risk factor. In this study, blood pressure was measured 3 times using a standardized protocol adapted from procedures recommended by the American Heart Association. 7 Participants were then classified as having hypertension if, on the basis of all available blood pressure measurements, they had systolic blood pressure 140 mm Hg and/or diastolic blood pressure 90 mm Hg, and/or they reported that they were currently taking antihypertensive medication. Participants who reported having smoked 100 cigarettes during their lifetime were classified as current smokers if they answered affirmatively to the question Do you smoke cigarettes now? The NCEP ATP-III guidelines have defined a family history of premature CHD as CHD in a first-degree male relative at 55 years of age or in a first-degree female relative at 65 years of age. However, a family history of CHD from the InterA- SIA study was limited to a history of myocardial infarction at 50 years among first-degree relatives, so this criterion was used to identify a family history of premature CHD. The number of major CHD risk factors present was determined by summing the number of risk factors and subtracting 1 for those who had a high HDL cholesterol level ( 60 mg/dl). CHD and CHD risk equivalents: The presence of CHD was assessed as a self-reported history of a heart attack. CHD risk equivalents were defined (assessed) as a history of stroke (self-report), diabetes mellitus (self-reported history of diabetes mellitus with concurrent medication use and/or a fasting plasma glucose of 126 mg/dl), angina (Rose questionnaire), or 20% risk of CHD within the next 10 years. Although the ATP-III guidelines have recommended using the Framingham risk equation to estimate a patient s 10-year CHD risk, this formula has been reported to overestimate the 10-year CHD risk in the Chinese population. Therefore, we used the calibrated 10-year CHD risk equation developed by Liu et al, in the Chinese Multi-Provincial Cohort Study. 8,9 ATP-III risk categories: The ATP-III guidelines classify patients into 1 of 3 mutually exclusive risk categories. The lowest risk category includes those without CHD or CHD risk equivalents and with 0 or 1 major CHD risk factor. The intermediate risk category includes those without CHD or its risk equivalents but with 2 CHD risk factors. The high-risk category includes those with CHD or a CHD risk equivalent. The institutional review board at the Tulane University Health Sciences Center and relevant ethics committees and other regulatory bodies in China approved the study. All participants provided written informed consent before data collection. During the study, participants with untreated conditions identified during the examination were referred to their usual primary healthcare provider. Statistical analysis: The prevalence of ATP-III defined CHD or CHD risk equivalents and major CHD risk factors was determined separately for men and women. The distribution of the population into the NCEP ATP-III defined risk categories was determined by age group (35 to 44, 45 to 54, 55 to 64, and 65 to 74 years), gender, and geographic location of residence (north, south, urban, and rural China). Differences across groups were assessed using the Wald chi-square test. The percentage of the population that was a candidate for therapeutic lifestyle changes and for whom drug therapy should be considered to lower their LDL cholesterol was also calculated, as was the percentage of participants who were aware of their diagnosis of high cholesterol and were candidates for therapeutic lifestyle changes and/or for treatment with lipid-lowering drug therapy. The percentages who adopted therapeutic lifestyle changes and were taking cholesterol-lowering medications among those who were aware of their diagnosis of having high blood cholesterol and among all those for whom therapeutic lifestyle changes and consideration of drug therapy were recommended according to the NCEP ATP-III guidelines were calculated. The total number of Chinese adults for whom therapeu-

1262 The American Journal of Cardiology (www.ajconline.org) Table 1 Prevalence of coronary heart disease (CHD) or risk equivalents and CHD risk factors in Chinese men and women, aged 35 to 74 years Variable Men Women CHD or risk equivalents Any 9.7% (0.4) 12.2% (0.5) Myocardial infarction/stroke 2.2% (0.2) 1.6% (0.2) Diabetes mellitus 4.8% (0.3) 5.5% (0.3) Angina pectoris 2.8% (0.2) 4.9% (0.3) 10-yr risk of CHD 20% 0.1% (NA) 0.1% (0.1) CHD risk factors* 2 Risk factors 47.6% (0.8) 15.7% (0.6) Cigarette smoking 60.2% (0.8) 6.9% (0.4) Hypertension 28.2% (0.7) 25.6% (0.7) Age 45 yrs in men 61.4% (0.8) 31.0% (0.7) Age 55 yrs in women Family history of CHD 1.6% (0.2) 1.5% (0.2) HDL 40 mg/dl 21.3% (0.6) 15.4% (0.5) HDL 60 mg/dl 23.1% (0.7) 25.9% (0.7) Data are presented as percentages (SEs). * Among participants without coronary heart disease or risk equivalents. NA not applicable (sample size too small [n 20] to permit reliable estimate). Table 2 Prevalence of Adult Treatment Panel III (ATP III) risk categories in adult Chinese population Variable CHD or Risk Equivalents* ATP III Risk Category 2 Risk Factors 0 1 Risk Factor Total 10.9% (0.3) 28.7% (0.5) 60.3% (0.5) Age group (yrs) 35 44 6.6% (0.4) 11.2% (0.5) 82.2% (0.6) 45 54 11.2% (0.6) 34.0% (1.0) 54.9% (1.0) 55 64 15.3% (0.8) 44.3% (1.2) 40.3% (1.2) 65 74 17.1% (1.2) 47.5% (1.6) 35.4% (1.6) Men 9.7% (0.4) 43.0% (0.8) 47.4% (0.8) Women 12.2% (0.5) 13.8% (0.5) 74.0% (0.7) North 16.0% (0.6) 32.2% (0.8) 51.9% (0.8) South 7.3% (0.4) 26.2% (0.7) 66.5% (0.7) Urban 15.2% (0.5) 29.1% (0.6) 55.7% (0.7) Rural 9.8% (0.4) 28.7% (0.6) 61.5% (0.6) Data are presented as percentages (SEs). * Included diabetes mellitus, angina, and presence of multiple risk factors such that 10-yr risk of CHD calculated by Framingham risk equation is 20%. Included cigarette smoking, hypertension, older age, family history of CHD, and low HDL cholesterol; high HDL cholesterol is protective CHD risk factor and offsets presence of 1 CHD risk factor. Without CHD or risk equivalents. p 0.001 comparing age groups, men and women, north and south, and urban and rural residence. tic lifestyle changes and drug therapy was recommended according to the NCEP ATP-III guidelines was estimated overall and stratified by gender, area of residence (north, south, urban, and rural), and ATP-III risk category. Additionally, because therapeutic lifestyle changes have the potential to lower LDL cholesterol, we calculated the number and percentage of adults in China for whom drug therapy should be considered according to the NCEP ATP-III guidelines even if their LDL cholesterol were to decrease by 10%. Finally, the percentage and number of adults in China for whom therapeutic lifestyle changes and drug therapy should be considered was calculated using cutpoints determined from a 1997 report published in the Chinese Journal of Cardiology. 3 For this analysis, subjects were considered candidates for therapeutic lifestyle changes and drug therapy if their LDL cholesterol was 100 and 120 mg/dl, respectively, in the presence of CHD or CHD risk equivalents, or was 120 and 140 mg/dl, respectively, in the absence of CHD or CHD risk equivalents but in the presence of 2 CHD risk factors, or was 140 and 160 mg/dl, respectively, in the absence of CHD or CHD risk equivalents in the presence of only 0 to 1 CHD risk factor. All calculations were weighted to the 2000 civilian noninstitutionalized adult population of China using census data. Sampling weights were adjusted on the basis of the proportion of participants without a LDL cholesterol measurement in each age and gender stratum. Using this approach, sampling weights were corrected for differences in missing data across age gender strata, but it was assumed that data within each stratum were missing at random. The survey commands in STATA software (College Station, Texas) were applied to account for the complex sampling design of InterASIA and obtain variance estimates. 10 Results The prevalence of CHD or CHD risk equivalents and 2 CHD risk factors are listed for men and women in Table 1. The most common CHD risk equivalent for men and women was diabetes mellitus. The most common CHD risk factors among men were cigarette smoking and age 45 years. Hypertension and age 55 years were the most common CHD risk factors among women. Table 2 lists the distribution of the InterASIA population into the ATP-III defined CHD risk categories. The presence of CHD or CHD risk equivalents was progressively more common at older age, among women, and in residents of northern and urban areas of China. The presence of 2 CHD risk factors in participants without CHD or CHD risk equivalents was also more common at an older age and in northern China. A higher percentage of men than women had 2 CHD risk factors. The prevalence of 2 CHD risk factors was similar among residents living in urban and rural areas of China. The percentage of the population without a CHD or CHD risk equivalent and with only 0 to 1 CHD risk factor was lower at an older age, among men, and in north and urban areas of China. The percentage of adults in China with a LDL cholesterol level that warranted therapeutic lifestyle changes and drug therapy as defined by the NCEP ATP-III guidelines is listed in Table 3. A low percentage of those in whom

Preventive Cardiology/Cholesterol Treatment in China 1263 Table 3 Percentage of Chinese adults in whom therapeutic lifestyle changes and consideration of drug therapy were indicated, were aware of their diagnosis of high blood cholesterol, and were currently undertaking therapeutic lifestyle changes and drug therapy to lower cholesterol Variable Therapeutic Lifestyle Change Consideration of Drug Therapy Recommended Aware* Treated Treated* Recommended Aware* Treated Treated* Total 18.2% (0.4) 10.7% (0.8) 62.0% (3.7) 6.7% (0.6) 7.4% (0.3) 13.4% (1.3) 33.7% (5.4) 4.5% (0.9) Age group (yrs) 35 44 10.0% (0.5) 5.6% (1.1) 75.5% (6.4) 4.4% (1.1) 3.0% (0.3) 5.4% (1.7) NA NA 45 54 18.0% (0.8) 11.2% (1.5) 57.6% (7.0) 6.4% (1.2) 6.8% (5.1) 12.8% (2.6) 49.6% (10.9) 6.4% (2.2) 55 64 27.7% (1.0) 14.2% (1.5) 66.5% (5.3) 9.6% (1.3) 11.8% (0.8) 19.5% (2.7) 22.2% (6.1) 4.3% (1.3) 65 74 29.8% (1.5) 10.3% (1.8) 53.4% (9.2) 5.5% (1.1) 15.9% (1.2) 12.1% (2.5) 41.6% (11.9) 5.0% (2.2) Men 18.8% (0.6) 10.6% (1.0) 68.3% (4.7) 7.3% (0.9) 6.7% (0.4) 14.4% (2.1) 30.2% (7.6) 4.3% (1.3) Women 17.5% (0.6) 10.7% (1.1) 55.0% (5.6) 6.0% (0.8) 8.2% (0.4) 12.5% (1.7) 37.1% (7.6) 4.6% (1.3) North 26.0% (0.7) 14.5% (1.2) 66.6% (4.4) 9.7% (1.0) 11.3% (0.5) 17.2% (1.9) 35.5% (6.4) 6.1% (1.4) South 12.5% (0.5) 4.8% (0.5) 41.0% (5.4) 2.1% (0.4) 4.6% (0.3) 6.6% (0.9) 25.2% (5.8) 1.7% (0.5) Urban 25.8% (0.6) 15.4% (0.9) 55.3% (3.1) 8.7% (0.7) 11.3% (0.4) 18.8% (1.5) 20.8% (3.5) 3.9% (0.7) Rural 16.2% (0.5) 8.8% (1.0) 66.8% (6.0) 5.9% (0.8) 6.4% (0.3) 11.0% (1.8) 43.5% (8.7%) 4.8% (1.3) Data are presented as percentages (SEs). * Among all patients recommended therapeutic lifestyle changes or consideration of drug therapy. Based on NCEP ATP-III guidelines. Of those aware of their diagnosis of high blood cholesterol. p 0.0001; p 0.01; p 0.05, comparing rates across age group (trend), men and women, north and south, and urban and rural residence. NA not applicable (sample size too small [n 20] to permit reliable estimate). Figure 1. Number of Chinese adults who were candidates for therapeutic lifestyle changes or consideration of drug therapy using current LDL cholesterol levels and after 10% reduction in LDL cholesterol. lifestyle changes and drug therapy would be recommended reported being aware of their diagnosis of high blood cholesterol. However, most patients aware of their diagnosis of high LDL cholesterol had initiated therapeutic lifestyle changes, with drug therapy used by approximately 1/3 of patients aware of their diagnosis of high LDL cholesterol. Overall, 10% of Chinese adults for whom therapeutic lifestyle changes and drug therapy to lower LDL cholesterol was indicated were receiving such treatment. The recommendation for therapeutic lifestyle changes and for consideration of drug therapy and the awareness of these recommendations were more common at an older age and in northern and urban areas of China (Table 3). The percentage of men and women for whom therapeutic lifestyle changes was recommended and the rates of awareness were similar for men and women. In contrast, consideration of drug therapy was recommended for a higher percentage of women than men. The adoption of therapeutic lifestyle changes was more common among residents of northern China than their counterparts living in the south. Among all those with elevated LDL cholesterol, the adoption of therapeutic lifestyle changes was more common in urban than in rural areas of China. However, among participants aware of their diagnosis of elevated LDL cholesterol, a higher percentage of rural, than urban, residents were taking drug therapy to lower their blood cholesterol. Finally, drug therapy was more common among northern, than among southern, residents with elevated LDL cholesterol. Overall, 85.9 million Chinese adults had a LDL cholesterol level at which the NCEP ATP-III guidelines recommend therapeutic lifestyle changes (Figure 1). Additionally, 35.0 million Chinese adults had an elevated LDL cholesterol level to the extent that the NCEP ATP-III guidelines recommend consideration of lipid-lowering drug therapy. Most patients for whom drug therapy was indicated had CHD or a CHD risk equivalent. A 10% population-wide reduction in LDL cholesterol would reduce the need for drug therapy by 45% to 19.3 million Chinese residents. Figure 2 presents the number of Chinese adults with an elevated LDL cholesterol who were candidates for therapeutic lifestyle changes and consideration of drug therapy according to NCEP ATP-III recommendations by age group, gender, geographic location, and urban or rural residence. The number of Chinese adults who were candidates for therapeutic lifestyle changes was highest in the 45- to

1264 The American Journal of Cardiology (www.ajconline.org) 54-year age group, and the number for whom drug therapy to lower their LDL cholesterol was indicated was highest in the 55- to 64-year age group. More men than women were candidates for therapeutic lifestyle changes, and consideration of drug therapy was indicated more often for women than for men. A greater number of northern, compared with southern, and rural, compared with urban, residents, respectively, were candidates for therapeutic lifestyle changes and consideration of drug therapy to lower their LDL cholesterol. Using the cutpoints from the 1997 Chinese National Cholesterol Treatment Guidelines, therapeutic lifestyle changes were indicated for 124.4 million Chinese adults (26.3%) and drug therapy to lower LDL cholesterol was indicated for 63.2 million adults (13.4%). Using these cutpoints, therapeutic lifestyle changes to lower LDL cholesterol were indicated for 34.6 million Chinese adults (67.0%) with CHD or a CHD risk equivalent and 49.5 million (36.4%) and 40.3 million (14.1%) Chinese adults without CHD or a CHD risk equivalent but with 2and0to1CHD risk factors, respectively. The corresponding numbers of Chinese adults who should be considered for drug therapy was 22.6 (43.8%), 24.4 (18.0%), and 16.2 million (5.7%), respectively. Discussion Figure 2. Number of male and female, northern and southern, and urban and rural dwelling Chinese adults who were candidates for therapeutic lifestyle changes and for whom drug therapy should be considered. Table 4 Number (in millions) and percentage of adults, 35 to 74 years old, in United States and China for whom therapeutic lifestyle changes or drug therapy to lower low density lipoprotein (LDL) cholesterol is indicated using National Cholesterol Education Program Adult Treatment Panel-III (NCEP ATP-III) guidelines Variable Therapeutic Lifestyle Changes United States China Consideration of Drug Therapy United States China n % n % n % n % Total 40.5 39.1% 85.9 18.2% 20.8 20.1% 35.0 7.4% Age group (yrs) 35 44 8.8 22.9% 18.2 10.0% 4.2 11.0% 5.6 3.0% 45 54 10.2 39.8% 25.9 18.0% 5.0 19.6% 9.8 6.8% 55 64 11.6 54.1% 23.8 27.7% 6.4 29.7% 10.1 11.8% 65 74 9.9 55.3% 17.8 29.8% 5.3 29.4% 9.5 15.9% Men 23.5 47.6% 45.6 18.3% 12.2 24.8% 16.1 6.7% Women 17.1 31.5% 40.3 17.5% 8.7 16.0% 18.9 8.2% The results of the present study suggest a substantial need for therapeutic lifestyle changes and/or consideration of drug therapy to lower LDL cholesterol levels in the Chinese general population. A high proportion of Chinese adults have a LDL cholesterol level higher than the cutpoints recommended for treatment in the NCEP ATP-III guidelines. Specifically, the results of our study suggest that 85.9 million Chinese adults should undertake therapeutic lifestyle changes and 35.0 million should be considered for drug therapy to lower their LDL cholesterol. However, only a very small proportion of those eligible had undertaken these risk reduction maneuvers. To provide a context for the present results, we compared the findings to corresponding results for the United States obtained from the Third National Health and Nutrition Examination Survey (NHANES III). Overall, a lower percentage of Chinese adults aged 35 to 74 years have elevated LDL cholesterol. Therapeutic lifestyle changes and consideration of drug therapy to lower LDL cholesterol are indicated for 39.1% and 20.1%, respectively, of adults in the United States and 18.2% and 7.4%, respectively, of Chinese adults (Table 4). In contrast, the absolute number of adults for whom therapeutic lifestyle changes and drug therapy to lower their LDL cholesterol is warranted is substantially higher in China than in the United States. Overall, therapeutic lifestyle changes aimed at lowering LDL cholesterol are recommended for 85.9 million Chinese adults 35 to 74 years of age compared with 40.5 million adults in the United States. Furthermore, according to the NCEP guidelines, drug therapy should be considered to lower LDL cholesterol levels in almost twice as many adults in China compared with the United States (35.0 vs 20.8 million, respectively).

Preventive Cardiology/Cholesterol Treatment in China 1265 Among the Chinese population with elevated LDL cholesterol, the proportion of subjects aware of this diagnosis and currently receiving treatment for their elevated LDL cholesterol was extremely low (6.7%). A major barrier to awareness of high LDL cholesterol is the low frequency of measuring serum cholesterol in China. According to unpublished data from InterASIA, only 9.6% of the population reported ever having had a blood cholesterol measurement before the survey. The high prevalence of hypercholesterolemia and low awareness of this diagnosis highlights the need for routine blood cholesterol measurements for adults in China. Studies have noted that CHD is the leading cause of mortality worldwide. In 1990, CHD accounted for 6.3 million deaths. 11,12 Additionally, cardiovascular disorders were found to be the leading cause of death in all world regions except India and Sub-Saharan Africa, where it was among the 3 leading causes of death. A recent analysis found that interventions to lower cholesterol concentration, including mass media health and patient-level education and treatment for high cholesterol, are very cost effective strategies. 13 For example, projected costs were as low as $32 per year for disability-adjusted life year saved in economically developing regions that included China. 13 The NCEP ATP-III guidelines provide treatment recommendations based on patients LDL cholesterol levels in conjunction with their absolute CHD risk. However, these guidelines are based on treatment trials and cohort studies from Western populations. A recent study from the Chinese Multi-Provincial Cohort Study indicated a much lower CHD incidence rate in China compared with the population in Framingham, Massachusetts. 8,9 In the present analysis of a representative sample of Chinese adults, 1% of the population had a 10-year CHD risk 20% after calibrating the Framingham risk equation. 8,9 In contrast, using the Framingham risk equation without calibration, 9.7% of men and 1% for women had a 10-year CHD risk 20% (data not shown). Given the differential in 10-year predicted CHD risk among men, it is necessary to understand the magnitude of CHD risk reduction achievable and the associated cost effectiveness of applying the NCEP ATP-III drug treatment guidelines to the Chinese population. Randomized controlled trials have demonstrated the benefit of statin therapy in lowering LDL cholesterol among Chinese adults. A report from China has recommended the use of cutpoints lower than those recommended in the NCEP ATP-III guidelines to initiate treatment. The lower cutpoints result in 63.2 million adults who should be considered for pharmacologic lipid-lowering therapy. Randomized controlled trials and prospective cohort studies should be conducted in the Chinese population to determine who would benefit most from pharmacologic cholesterol-lowering treatment. 1. NCEP Expert Panel. 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. Grundy SM, Cleeman JI, Merz CN, Brewer HB Jr, Clark LT, Hunninghake DB, Pasternak RC, Smith SC Jr, Stone NJ. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation 2004;110:227 239. 3. Qi F, Zhonglin W, Tianhai N, Geng S, Zaijia C, Zongliang L, Chuanxiong L, Beifan Z, Junren Z, Yongkang Z, et al. Suggestions of prevention and treatment of dyslipidemia. Chin J of Cardiol 1997;255: 169 175. 4. He J, Neal B, Gu D, Suriyawongpaisal P, Xin X, Reynolds R, Mac- Mahon S, Whelton PK. International collaborative study of cardiovascular disease in Asia: design, rationale, and preliminary results. Ethn Dis 2004;14:260 268. 5. Allain CC, Poon LS, Chan CS, Richmond W, Fu PC. Enzymatic determination of total serum cholesterol. Clin Chem 1974;20: 470 475. 6. Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem 1972;18:499 502. 7. Perloff D, Grim CE, Flack JM, Frohlich ED, Hill M, McDonald M, Morgenstern BZ. Human blood pressure determination by sphygmomanometry. Circulation 1993;88:2460 2470. 8. 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. 9. Liu J, Hong Y, D Agostino RB Sr, Wu Z, Wang W, Sun J, Wilson PW, Kannel WB, Zhao D. Predictive value for the Chinese population of the Framingham CHD risk assessment tool compared with the Chinese Multi-Provincial Cohort Study. JAMA 2004;291:2591 2599. 10. StataCorp. STATA statistical software, release 6.0. College Station, TX: STATA Corporation, 1999. 11. Lopez AD. Assessing the burden of mortality from cardiovascular diseases. World Health Stat Q 1993;46:91 96. 12. Murray CJL, Lopez AD. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Boston: Harvard School of Public Health, 1996:1 990. 13. Ezzati M, Hoorn SV, Rodgers A, Lopez AD, Mathers CD, Murray CJ. Estimates of global and regional potential health gains from reducing multiple major risk factors. Lancet 2003;362:271 280.