Can we afford to treat hyperlipidaemia as we should?: Strategies for rational treatment

Abstract

There is no debate about whether patients with established coronary heart disease (CHD) should receive cholesterol-lowering drug therapy: the great majority should, certainly those whose serum cholesterol exceeds 5 mmol/l. In primary CHD prevention the indication for lipid-lowering drug therapy is largely determined by the absolute risk of CHD. There is considerable disagreement about the level of absolute risk at which such treatment should be commenced. The relative absence of side-effects of the statin drugs and their relatively high cost means that issues of cost-effectiveness are of more concern for state health services than the balance between benefits of therapy and adverse events. Thus, the degree of risk at which they are recommended appears to be largely determined by the type of healthcare system a nation has and the frequency of high risk individuals in that nation. In Britain, which has both state healthcare and numerous high risk patients, the cost of primary prevention with statins except at extreme risk is viewed as prohibitive, whereas the CHD risk at which lipid-lowering drugs are recommended is lower in the USA, where healthcare costs are borne more directly by the patient, and in European countries with lower rates of CHD. Whatever level of risk is recommended for the use of lipid-lowering drugs in primary CHD prevention, the clinician should be in a position to assess CHD risk in an individual with a reasonable degree of accuracy. When recommended algorithms and charts were compared with calculations of risk using the equations derived from the Framingham Study, on which they are based, they were shown to be inaccurate. High density lipoprotein cholesterol emerged as a particularly important risk factor, which when omitted led to underestimation of risk in women and people with multiple risk factors. It is concluded that guidelines should be evaluated in the type of patient for whom they are intended. It is important to redress the balance between the numerous publications on the interpretation of clinical trials and the virtual absence of rigorous assessments of methods for determining CHD risk in clinical practice.