Intended for healthcare professionals


People at risk of coronary heart disease should not be denied treatment with effective drugs for purely financial reasons

BMJ 1998; 317 doi: (Published 04 July 1998) Cite this as: BMJ 1998;317:80
  1. T M Reynolds, Consultant chemical pathologist.,
  2. A S Wierzbicki, Senior lecturer in chemical pathology.,
  3. M A Crook, Consultant chemical pathologist.,
  4. N E Capps, Consultant chemical pathologist.
  1. Clinical Chemistry Department, Burton Hospital, Burton upon Trent DE13 0RB
  2. St Thomas's Hospital, London SE1 7EH
  3. Lipid Clinic, Princess Royal Hospital, Telford TF6 6TF

    EDITOR—As soon as effective treatments for coronary heart disease—which causes 30% of deaths in the United Kingdom—became available, evidence based medicine and finance clashed. The Standing Medical Advisory Committee attempted to impose the Sheffield risk tables1 and was condemned for its simplistic guidelines and high threshold for treatment.2 A report on cholesterol and heart disease by the NHS Centre for Reviews and Dissemination now seeks to reduce expenditure on statins by focusing clinical effort on modification of lifestyle and treatment for mild hypertension.3

    The relation between cholesterol and coronary heart disease is log-linear so a “normal” cholesterol concentration is a fallacy. Most people in the United Kingdom have high cholesterol concentrations and would benefit from lipid lowering. To reduce coronary heart disease in the United Kingdom people must change their lifestyles, but evidence for the success of lifestyle modification is depressing: participants in the OXCHECK study reduced their cholesterol concentrations by only 3% and their body mass by 2%.4

    The report admits that lowering cholesterol concentrations is beneficial but claims that statins are too expensive, compared with treatment for hypertension with off patent drugs. Many patients with hypertension, however, receive multiple patented drugs at a cost similar to that of statins.

    The cost of treatment of hypertension—number needed to treat=40 at a blood pressure of 170/100 mm Hg—is similar to that of primary prevention for high risk patients with cholesterol concentrations of 7 mmol/l. The west of Scotland coronary prevention study showed a 30% reduction in mortality despite a 30% dropout rate.5 The 7-year extension of the Scandinavian simvastatin survival study suggests a reduction of 47% in event rates in the treatment group. Lipid lowering may therefore be even more cost effective than previously believed.

    Treatment with statins is more effective than multidrug treatment for hypertension in reducing absolute risks: a 30% reduction can be achieved with a single drug, compared with 10% reductions for any single antihypertensive drug. Statins also have fewer side effects. The issue of statins approaching expiry of their patent is irrelevant. It is unethical not to treat people at risk of coronary heart disease with effective drugs for purely financial reasons—just as it would be unethical not to treat those who smoke or are obese.

    The report leaves us little further forward in deciding whom we should treat or where the necessary money should come from. Unfortunately its press release and the subsequent media reports convey a negative message to healthcare providers and to those patients who need to have their lipids measured and adequately treated.


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