Use of lipid lowering drugs for primary prevention of coronary heart disease: meta-analysis of randomised trials

The reduction in coronary events and in coronary mortality from
hypolipidemic therapy is well known, and it is resonable and reassuring to
find that this holds true in both primary and secondary prevention trials.

The authors make various excuses to explain the absence of a total
mortality reduction from hypolipidemic therapy in primary prevention
trials. Surely this suggests that hypolipidemic therapy is not free of
adverse effects, and the reduction in coronary mortality is balanced by an
excess mortality from a non-coronary cause. This effect is not seen in
secondary prevention trials because the contribution of coronary mortality
to total mortality is large, so that reduction in coronary mortality is
then reflected in a reduction of total mortality. In a primary prevention
study, the contribution from coronary mortality to total mortality is
moderate at best, and the consistent failure to find a total mortality
reduction emphasises the very important point that only high risk patients
should be treated in a primary prevention setting.

Cholesterol is essential for life and forms an integral part of the
cell membrane. We cannot reduce cholesterol for all and find no ill
effects of such action. The absence of a total mortality reduction in
primary prevention emphasises the utmost importance of hypolipidemic
therapy only in those suffering from, or will likely suffer from,
atherosclerotic disease.