BMJ  2006;332:1453 (17 June), doi:10.1136/bmj.332.7555.1453

Letter

Should we lower cholesterol as much as possible?

Cholesterol is good?

EDITOR—As Ravnskov et al state,¹ any revision of targets needs to be evidence based and responsible, taking into account the risks and benefits of such a measure. However, some of the authors' assertions are unclear and potentially misleading.

They do not explain in what way lowering coenzyme Q10 is harmful. The study of Rundek et al, one of the few that measured Q10 values, did so in insufficient numbers of patients, and the authors still conclude significance despite failing to show anything statistically solid.²

In one of the largest studies to date, the heart protection study, no evidence was found for neuropsychiatric and pulmonary side effects above placebo level.³ With regards to cancer, Ravnskov et al disregard recent evidence that statins seem to protect against several forms of cancer,⁴ not least colorectal cancer; instead, they favour older evidence. The heart protection study had cancer incidence (including various subtypes) as an end point, and no increased cancer risk was found in that trial.³

With respect to the authors' competing interests, three of them dispute the very association between hypercholesterolaemia and heart disease. In familial hypercholesterolaemia, in which young adults with no other risk factors may develop accelerated atherosclerosis, the underlying biochemical abnormality is well known (defects in low density lipoprotein receptors), thus making the authors' hypothesis almost completely untenable.

That a large proportion of the population may require pharmacological prophylaxis for cardiovascular disease seems counterintuitive. However, dietary patterns have deteriorated, we are in the middle of an obesity epidemic, and dietary measures are generally insufficient to mitigate cardiovascular risk in both hypercholesterolaemia and obesity. With the benefits of statins documented in several large studies, why deny statin treatment on the basis of comparatively inconclusive evidence?

Enfield EN2 8JL jfdwolff{at}doctors.org.uk

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Competing interests: None declared.

References

1. Ravnskov U, Rosche PJ, Sutter MC, Houston MC. Should we lower cholesterol as much as possible? BMJ 2006;332: 1330-2. (3 June.)[Free Full Text]
2. Rundek T, Naini A, Sacco R, Coates K, DiMauro S. Atorvastatin decreases the coenzyme Q10 level in the blood of patients at risk for cardiovascular disease and stroke. Arch Neurol 2004;61: 889-92.[Abstract/Free Full Text]
3. Heart Protection Study Collaborative Group. MRC/BHF heart protection study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002;360: 7-22.[CrossRef][ISI][Medline]
4. Poynter JN, Gruber SB, Higgins PD, Almog R, Bonner JD, Rennert HS, et al. Statins and the risk of colorectal cancer. N Engl J Med 2005;352: 2184-92.[Abstract/Free Full Text]

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Should we lower cholesterol as much as possible?

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Rapid Responses:

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Should we lower cholesterol as much as possible? Authors´ response

Uffe Ravnskov, et al.
bmj.com, 27 Jun 2006 [Full text]

Cholesterol is good?

Jacob F. de Wolff
bmj.com, 28 Jun 2006 [Full text]

RE: Cholesterol is good?

Nigel Kinbrum
bmj.com, 19 Jul 2006 [Full text]