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BMJ No 7122 Volume 315 Letters Saturday 13 December 1997
Use of statinsSee Editorial by Muldoon p1554Guidelines need to concentrate on reducing overall cardiovascular riskEditorWe agree with Freemantle et al that all cases of established atheroma need treatment,(1) as established in the 4S (Scandinavian simvastatin survival study) and CARE (cholesterol and recurrent events) study. Patients who have had coronary artery bypass surgery need even more aggressive treatment.(2) We disagree with an analysis based solely on deaths avoided. The NHS has no effect on the outcome total mortality. Any cost effectiveness study of lipid reduction by the NHS needs to focus on morbidity and efficiency of care (events avoided, procedures saved, hospital stays reduced). Deaths postponed are a welcome bonus. The statin studies are convincing and suggest a prevention rate of 1 in 13-25 (not 1 in 55 as the authors say), at a cost of £#163;5,000-8,000.(3) The implications for primary care of the prescription of statins in men after WOSCOPS (west of Scotland coronary prevention study) are huge. The effects will be greater once large pooled single agent studies show the benefits of lipid reduction in women, elderly people, patients with strokes, and those with diabetes. Pilot data on the diabetic subgroup in the 4S study suggest large reductions in events.(4) The primary prevention Sheffield tables recommended (based on a 10 year risk of coronary heart disease of 30%) are at variance with the international consensus (10 year risk of 20%). Many would disagree with them. The likely cost of statins is horrendous. It is the bill for 50 years of neglect of advice on diet and lifestyle. Statins are one of the most effective treatments available for reducing mortality from and morbidity of atheroma. Are we to deny patients effective treatment for coronary disease because it is expensive? Or should we negotiate better terms nationally or use class competitors, since all forms of lipid reduction reduce events? Maybe we ought to consider the whole cardiovascular drug budget. The idea that lipids and mild hypertension should be managed separately is antiquated. Recommendations by the World Health Organisation state that mild hypertension (180/105 mm Hg) should be managed as part of overall cardiovascular risk.(5) The treatment of hypertension is less effective in terms of events (1 in 131 events). Should we switch priorities? It is an open question. The Standing Medical Advisory Committee's guidelines need complete revision. Their aim should be to guide the whole medical profession in how to reduce overall cardiovascular risk most effectively, not just concentrate on one aspect. A S Wierzbicki
Senior lecturer in chemical
pathology
T M Reynolds
Consultant chemical
pathologist
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 Post-Coronary Artery Bypass Graft Trial Investigators. The
effect of aggressive lowering of low-density lipoprotein cholesterol
levels and low dose anticoagulation on obstructive changes in saphenous
vein coronary bypass grafts. N Engl J Med
1997;336:153-62.
3 Johanneson M, Jonsson B, Kjekshus J, Olsson A G, Pedersen T R,
Wedel H on behalf of the Scandinavian Simvastatin Survival Study Group.
Cost-effectiveness of simvastatin treatment to lower cholesterol levels
in patients with coronary heart disease. N Engl J Med
1997;336:322-6.
4 Pyorala K, Pedersen T R, Kjekshus J, Faergeman O, Olsson A G,
Thorgeirsson G. Cholesterol lowering with simvastatin improves
prognosis of diabetic patients with coronary heart disease.
Diabetes Care 1997;20:614-20.
5 Chalmers J, Zanchetti A. The 1996 report of a World Health
Organisation expert panel on hypertension control. J
Hypertens 1996;14:929-33.
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