Letters Views on lipid lowering

Author’s reply

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c5837 (Published 19 October 2010) Cite this as: BMJ 2010;341:c5837
  1. Rodney A Hayward, professor of medicine and public health1
  1. 1Schools of Public Health and Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
  1. rhayward{at}umich.edu

The estimated relative risk reduction (RRR) for total mortality of 9% for primary prevention is quite similar to the 11-12% found for secondary prevention.1 2 3 It is just as accurate to summarise the literature as finding no evidence that statins’ RRR for primary prevention differs much from that for secondary prevention but that their absolute risk reduction varies tremendously on the basis of the patient’s overall cardiovascular risk.3

In terms of the ongoing controversy about JUPITER and C reactive protein,1 the issues are the same as those we laid out for lipids. Statins’ mechanism(s) of action is an important scientific question,4 but the three relevant clinical questions for any biomarker are the same—does it help determine the risk of cardiovascular events in the absence of treatment (RiskNoRx), the relative risk reduction of treatment (RRRRx), and the risk of treatment harm (HarmRx)?

Net benefit=(RiskNoRx*RRRRx)─(HarmRx)

Strong evidence suggests that C reactive protein can add to assessing cardiovascular risk at the margins. However, we know of no good evidence that it modifies RRRRx. Rather than pressing for treatment of raised C reactive protein, we need to analyse whether statins RRRRx varies with baseline C reactive protein using available techniques and data.4 5

Until then, the best evidence currently available suggests that tailoring statin treatment to patients’ overall cardiovascular risk is likely to be the most effective and efficient strategy 3; that C reactive protein and lipid values should generally be used only to help estimate overall cardiovascular risk; and that other lipid therapies (including combination therapy) should show a significant impact on mortality or morbidity before being widely used clinically.


Cite this as: BMJ 2010;341:c5837


  • Competing interests: None declared.