Cholesterol lowering should be just one part of a multiple risk factor intervention

General practice pp (p 1120) -35

Distilling evidence from randomised controlled trials and observational studies into valid and usable guidelines is not easy. Despite unequivocal evidence that lowering cholesterol concentrations reduces mortality from coronary heart disease,1 producing guidelines on prevention that meet with universal agreement has proved difficult.2 Four articles in this week's issue illuminate the difficulties.

Unwin et al show that the application of different cholesterol guidelines leads to considerable variations in decisions to screen and to treat when applied to a representative population (p 1125).3 This is not surprising when the content and recommendations of the cholesterol guidelines are studied (see their table 1). A previous study in the United States showed a similar magnitude of disagreement between older and newer versions of the US guidelines, Canadian guidelines, and a coronary risk model derived from Framingham data.4 In the US study the Framingham model proved to be the most accurate method to predict future coronary heart disease mortality. On this basis it is comforting to see that two of the guidelines analysed by Unwin et al—the Sheffield and European guidelines—base their recommendations on …