The American College of Cardiology (ACC) and the American HeartAssociation (AHA) expert panel, together with other partner organisa-tions, have recently published a clinical guideline on lowering bloodcholesterol to prevent cardiovascular disease (Stone et al., 2014). Incontrast to a previous comprehensive guideline on the identificationand treatment of dyslipidaemia (National Cholesterol EducationProgram Expert Panel on Detection, E, and Treatment of High BloodCholesterol in Adults (Adult Treatment Panel III), 2002), this currentreportaddressesalimitedbutcriticalsetofclinicalquestions,whichpri-marily relate to the use of statins as the primary pharmacologic treat-ment strategy for adults aged ≥21 years. Key to the development ofthis guideline is recognising that randomised clinical trials (RCTs) andmeta-analyses of these RCTs provide the highest quality of evidence.The panel recognises that most RCTs have been on statins, and strongevidence exists that the beneficial effect of statins in reducing athero-sclerotic cardiovasculardisease (ASCVD) is through their effecton low-ering blood low-density lipoprotein (LDL) cholesterol. However, in aclear departure from the previous guideline which used target levelsofbloodcholesteroltoguidetreatmentstrategies,thenewguidelinefo-cusesontreatmentusingfixeddosesofstatinstoreduceatheroscleroticcardiovascular disease for which good quality evidence from RCTs ex-ists.Thereportsuggeststhatthehighertheintensityofstatintreatment,the greater the reduction in blood LDL-cholesterol, the greater the re-ductioninASCVD. Except inafewclinicalscenarios,thisdictumapplieslargely in a wide variety of clinical settings. Thus, statin treatment maybe recommended for use for individuals with different characteristics(although dosages or intensity of treatment may vary depending onthe individual's background risk and patient preference).InthisissueofPreventiveMedicine,Dr.Nuneshasarguedthatthereisan apparent inconsistency between this ‘philosophy’ espoused by theACC/AHA expert panel of using high quality evidence from RCTs andtheactualrecommendationsthatit developed(Nunes, 2014). Inpartic-ular,Dr.Nunescitedthelackofclinicaltrialevidencetosupporttheuseof 20 mg rosuvastatin as high-intensity therapy and 2 to 4 mgpitavastatin as moderate-intensity therapy for secondary preventionof ASCVD (Table 5 in the published guideline). There is some validityin raising these points. The expert panel based their recommendationslargelyonthefindingsoftheJUPITERtrialwhichisaprimarypreventionRCTforrosuvastatintherapy(Ridkeretal.,2008).TherehasbeennoRCTthathasexaminedtheeffectofthistreatmentforsecondaryprevention.Readingthedetailsoftheguidelinehighlightsanimportantperspectivetakenbytheexpertpanel.Asindicatedabove,theexpertpanelhascon-cluded that the use of statins is effective in a wide range of clinical set-tings. Indeed, it has been estimated that cardiovascular eventsdecrease by 20% for each mmol/l reduction in LDL-cholesterol due tostatin treatment, an effect seen in those with or without any priorhistory of cardiovascular disease (Cholesterol Treatment Trialists et al.,2010). Thus, the expert panel suggests that there is ‘no differentiationbetween the specific statins and doses used in primary and secondaryprevention RCTs’ since high quality evidence suggest that reducingASCVD by statin therapy is a ‘class effect related to the reduction inLDL-cholesterol’. Thus, the lack of secondary prevention RCT forrosuvastatin does not preclude its recommendation for the use of thisdrug either for primary or for secondary prevention of ASCVD. It alsobears reading the full report of the panel which, in fact, recommendsusing20mgrosuvastatinasanalternativetohigh-intensityatorvastatintreatment,forwhichthereissubstantialevidence fromRCTstosupportits use, if the latter drug could not be tolerated.Moreover, the guideline also lists recommended drugs for high-,moderate-, and low-intensity statin therapy (Table 5 in the report).Dr. Nunes rightly questions the inclusion of moderate-intensity therapyof 2 to 4 mg pitavastatin since there is currently no RCT for this therapyinvolving clinical cardiovascular disease endpoints. Table 5 of thepublished report shows that a number of drugs, including pitavastatin,have been written in italics. The footnote indicates that these italiciseddrugsarestatinswhichtheexpertpanelhasnotreviewedforthisreportbut are approved for use by the U.S. FederalDrug Agency (FDA). It is pos-sible that some of these drugs have shown efficacy in reducingLDL-cholesterol but RCTs showing their effect in reducing ASCVDremain to be seen, or at least, have not been reported just yet withinthe time frame of the review conducted for this guideline. It is useful toknow which statins are approved by the FDA (or any other relevant reg-ulatory agency) but to list these drugs together with the panel'srecommendations, without any apparent rationale, could easily lead toconfusion.Dr. Nunes then digresses towards the issue of using all-causemortality as the key outcome for RCTs to inform therapeutic strategiesfor secondary prevention. It may help to look back again at the firstsentence of the preamble of the guidelines which states that goals ofthe ACC and the AHA are to ‘prevent cardiovascular disease …, improvemanagement of people with the disease …, and develop guidelines … thatpromote optimal patient care and cardiovascular health ’. To an extent, the