(Circulation. 1996;93:1774-1776.)
© 1996 American Heart Association, Inc.
Articles |
Cost of Prevention
The Case of Lipid Lowering
From the Division of Cardiology and Preventive Cardiology and Therapeutics Program, Hamilton Civic Hospitals Research Centre, McMaster University, Hamilton, Ontario, Canada.
Correspondence to Dr Salim Yusuf, Hamilton General Hospital, 237 Barton St E, Hamilton, Ontario, Canada L8L 2X2. E-mail yusufs@fhs.mcmaster.csu.ca.
Key Words: Editorials • cost-benefit analysis • epidemiology • prevention • cholesterol
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Introduction |
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A vast body of epidemiological studies has demonstrated a continuous relationship between serum cholesterol levels and CHD whereby the risk of CHD increases across the entire range of cholesterol values. A 10% reduction in cholesterol level over a period of several decades has been associated with a 30% reduction in CHD incidence, after correction for a number of confounders and adjustments for measurement errors.1 Clinical trials not only have addressed the question whether decreases in cholesterol levels will reduce CHD but have demonstrated how soon such benefits may be observed. Furthermore, comparison of the magnitude of benefit of relatively short-term treatment in the trials (eg, a few years) versus the theoretical maximum of long-term differences predicted from the epidemiological studies (eg, several decades) provides a framework to assess the potential long-term benefits of sustained cholesterol reduction, well beyond the duration of the trials.
The first generation of lipid-lowering trials (Helsinki [gemfibrozil],2 WHO [clofibrate],3 LRC-CPPT [cholestyramine]4 ) used drugs that lowered cholesterol only modestly (about 10%); some of these drugs produced side effects, so that compliance with treatment was suboptimal, and the studies were consequently inadequately powered to provide reliable estimation of the effects of lipid lowering on mortality. Although at first glance, the results of these trials appeared to be inconclusive or even contradictory, a comprehensive overview of these trials in an epidemiological context1 provided a coherent result: the gains in CHD reduction were related to the degree of cholesterol lowering and the duration of the intervention.
More recently, with
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