Intended for healthcare professionals


Secondary prevention in coronary heart disease

BMJ 1999; 318 doi: (Published 22 May 1999) Cite this as: BMJ 1999;318:1419

Effects of statins have been in addition to those of aspirin and

  1. Jonathan Morrell, Committee member, health care section of British Hyperlipidaemia Association
  1. Fitznells Manor Surgery, Ewell, Surrey KT17 1TF
  2. West Midlands Centre for Adverse Drug Reaction Reporting, City Hospital, Birmingham B18 7QH

    EDITOR—Ferner acknowledges the apparent similarity between the abilities of continuing aspirin and simvastatin to prevent “bad things.”1 He overlooks the fact that the positive outcomes of the secondary prevention statin studies were additional to the use of both aspirin and β blockers according to the investigators' cardiological practices at the time (table).24 Since the inception of the Scandinavian simvastatin survival study over a decade ago, subsequent trials have tested lipid modification with statins against a background of increasingly optimal practice, comfortably exceeding that described in the survey by Campbell et al.5

    Percentages of patients in each study who were taking aspirin or blockers

    View this table:

    Ferner's argument is focused on cost effectiveness. The cost implications of aspirin, however, are negligible—indeed, many patients buy it themselves. The cost effectiveness of statins in secondary prevention is established, equates to that of other accepted healthcare interventions, and will improve further as patents expire.

    The benefits of aspirin and β blockers are beyond doubt, but Ferner's message serves to inhibit further the implementation of treatment with statins in secondary prevention and the potential for further reductions in mortality and morbidity. Surely it is better to offer patients requiring secondary prevention the complete range of lifestyle and therapeutic options and, for cost savings, to concentrate on areas of less substantiated prescribing.


    • Competing interests Dr Morrell has received fees from pharmaceutical companies marketing lipid lowering drugs for speaking at and organising educational meetings.


    Author's reply

    1. R E Ferner (r.e.ferner{at}, Director
    1. Fitznells Manor Surgery, Ewell, Surrey KT17 1TF
    2. West Midlands Centre for Adverse Drug Reaction Reporting, City Hospital, Birmingham B18 7QH

      EDITOR—The proportion of patients receiving aspirin in the trials to which Morrell refers is encouraging. Evidence from Campbell et al's study suggests that many more patients could benefit from aspirin than receive it.1 Even in the trials, few patients were treated with β adrenoceptor antagonists, which are underused.2 An important secondary prevention study from Southampton, which quoted high rates of use of aspirin, did not provide information about β blockers.3

      Chen et al highlighted the difference between America's “best hospitals” and the rest by examining the outcomes for nearly 150 000 elderly patients who had had heart attacks.4 One patient in 25 admitted to the best hospitals survived who would have died in the other hospitals. The authors ascribed this to two straightforward facts: 15% more patients were given aspirin and over 25% more patients were given β blockers in the best hospitals.

      Morrell rightly points out that the benefits of aspirin and statins may be additive. However, the benefits of statins, even in this high risk population, fall short of miraculous. In one study (the long term intervention with pravastatin in ischaemic disease study) the absolute benefit of pravastatin 40 mg daily was to save 1.9 lives per 610 patient years of treatment.5 That is one life saved for every 320 patient years of treatment, at a direct drug cost of nearly £180 000—over 10 years' pay for an average wage earner.

      When all patients who might benefit are taking aspirin and β blockers, which cost little, we can worry more about the expensive treatments, whose ability to reduce relative risk is heavily promoted but whose absolute benefit is quite small.


      • bCompeting interests Dr Ferner advises Birmingham Health Authority on prescribing matters.


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