EDITOR—Ulrich et al have bravely attempted to tackle a problem that has been quietly sidestepped for some time—namely, that lipid lowering does not (as far as we are aware) prevent coronary heart disease, it merely postpones it.1 The concept of assessing treatment in terms of “event free life years gained” is a useful one, but using a risk calculator to estimate potential benefit is fraught with difficulty.

The authors base their calculation on the Framingham equation, in common with most coronary risk calculators, and have made one particularly common but incorrect assumption regarding age. With the publication of the Framingham equation, Anderson et al stated that the equation “may be used for estimating outcome probabilities over a range of 4 to 12 years for persons aged 30 to 74 years.”2 Quoting calculated risks for ages 15 to 94 is therefore inappropriate. To attempt to recalculate such risks using a pharmacologically lowered cholesterol concentration is even less appropriate.

Anderson's statement is also relevant to the notion of a “3% annual risk,” which cannot be reliably predicted by the Framingham equation directly. The joint British guidelines circumvent this by referring to a “30% 10 year risk,” which will in fact identify subjects whose initial risk is less than 3% per year because the risk is higher in the later years.3

Finally, it should be remembered that the Framingham equation is less reliable at the extremes of any of the variables included; hence a very high cholesterol concentration in a young person should stimulate further clinical thought. Ulrich et al calculated the benefits of treatment for cholesterol concentrations of 9 mmol/l and higher. People with these concentrations require proper investigation of their dyslipidaemia rather than a keyboard exercise to estimate (badly) cardiovascular risk.

EDITOR—Ulrich et al …