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LETTERS:
Jonathan Morrell and R E Ferner
Secondary prevention in coronary heart disease
BMJ 1999; 318: 1419 [Full text]
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[Read Rapid Response] Excessive emphasis on statins in the prevention of coronary disease
H T Ong   (23 May 1999)

Excessive emphasis on statins in the prevention of coronary disease 23 May 1999
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H T Ong,
Consultant cardiologist
H T Ong Heart Clinic, Penang, Malaysia

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Re: Excessive emphasis on statins in the prevention of coronary disease

It is heartening to note that there are practical clinicians who realise the important role aspirin and beta blockers play in the secondary prevention of coronary disease. Furthermore, there is evidence from the American Physician Health Study of the value of aspirin in the primary prevention of coronary disease in high risk subjects. Similarly, the overall balance suggests that beta blockers are useful in the primary prevention of coronary disease as they do reduce cardiac events in the treatment of hypertensive patients. In contrast, the trials show that statins do not reduce mortality in the primary prevention studies. The mortality reduction in the WOSCOPS trial just failed to reach a significant level (p=0.051) even though the subjects studied were at high risk of coronary events, being middle aged obese males with very high cholesterol levels, more than a third of whom smoked. In the other major primary prevention trial,the AFCAPS/TexCAPS study, the subjects were at only moderate risks of coronary events and the number of deaths in the treatment group exactly matched the control group. We should thus be very clear about the message of the studies. Statins are useful in the secondary prevention of coronary disease but at a significant financial cost. In primary prevention, there is a reduction in coronary events but not in overall mortality, so that the physician must be very selective to treat only the subjects at high risk of coronary artery disease. Otherwise, he will be expanding a lot of resources and not making an impact on the mortality rate of the community. It is certainly better and more logical to use aspirin and beta blockers, both of which have been around longer,are cheaper and have better evidence supporting them.