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BMJ No 7122 Volume 315 Letters Saturday 13 December 1997 Use of statins See Editorial by Muldoon p 1554 Other, cheaper and simpler, measures should be tried first Editor We agree with Freemantle et al's editorial pointing out that the Standing Medical Advisory Committee's advice on statins is deficient and that there is considerable potential for harm outweighing the good.(1) The committee's advice is based on multifactorial risk assessment but fails to recognise the range of interventions known to be effective. Thus smoking cessation, aspirin, ß blockers, and angiotensin converting enzyme inhibitors have important roles in secondary prevention. While the individual's risk is important, so too is the population impact of treatment interventions. We know that smoking cessation and aspirin are cheap and safe, so is it not appropriate to use them first? Unfortunately, these simple measures are not used a lot of the time.(2) The addition of ß blockers is the next most cost effective intervention, and this has the merit of not needing repeated diagnostic tests. We suspect that the marginal benefit of adding statins is small and that the number needed to treat to prevent a coronary event or death will be large. We agree with the editorial that the effort and resources expended in cholesterol management could distract patients and their doctors from the more cost effective interventions. We note that in the 4S trial (Scandinavian simvastatin survival study) 63% of high risk patients were not taking aspirin and 43% were not taking a ß blocker.(3) It would be valuable to know how the impact of statins varied between these patients and those who were taking aspirin or ß blockers, or both, and it is to be hoped that such an analysis will be forthcoming. Our concern is that the greatest improvement in the health of our population should be secured by the best use of available resources. Peter Sheridan Consultant in public health medicine Peter Saveg Primary care medical adviser Sue Silverman Pharmaceutical adviser Enfield and Haringey Health Authority, Barnet, Hertfordshire EN4 0DR References 1 Freemantle N, Barbour R, Johnson R, Marchment M, Kennedy A. The use of statins: a case of misleading priorities? BMJ 1997;315:826-8. (4 October.) 2 Eccles M, Bradshaw C. Use of secondary prophylaxis against myocardial infarction in the north of England. BMJ 1991;302:91-2. 3 Scandinavian Simvastatin Survival Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian simvastatin survival study (4S). Lancet 1994;344:1383-9. Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline