Intended for healthcare professionals


Shifting views on lipid lowering therapy

BMJ 2010; 341 doi: (Published 28 July 2010) Cite this as: BMJ 2010;341:c3531
  1. Harlan M Krumholz, Harold H Hines, Jr, professor of medicine123,
  2. Rodney A Hayward, co-director 45
  1. 1Section of Cardiovascular Medicine and Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT 06510, USA
  2. 2Section of Health Policy and Administration, School of Public Health, Yale University School of Medicine
  3. 3Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven
  4. 4Health Services Research and Development Center of Excellence, Ann Arbor, VA Medical Center, Michigan, USA
  5. 5Schools of Public Health and Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
  1. Correspondence to: H M Krumholz harlan.krumholz{at}
  • Accepted 21 April 2010

Harlan Krumholz and Rodney Hayward argue that preventive cardiology should be based as much as possible on strategies that are known to improve patient outcomes rather than focusing on biomarkers

Current guidelines and performance measures concerning risk factors for coronary artery disease emphasise the importance of achieving target cholesterol levels without strong guidance about the strategies used to achieve them. Some health programmes also pay doctors whose patients achieve specific lipid targets.1 The target approach opened the door for marketing campaigns to promote drugs that have not been shown to affect patient outcomes. For example, ezetimibe was heavily promoted in the United States, with the manufacturers spending more than $200m (£130m; €160m) on direct to consumer advertising of Vytorin (ezetimibe plus simvastatin) in 2007. Millions of prescriptions were written, even though no clinical trial of the drug had focused on patient outcomes.2 3 The focus on targets is out of alignment with evidence from clinical trials and discounts the importance of testing whether the benefits of a treatment exceed its risks, instead suggesting that we can rely on its effects on biomarkers.

Current US guidelines

The “treat to target” model, which focuses on cholesterol levels is deeply embedded in medical dogma. Current US guidelines, last published in 2004 and now under review, propose a low density lipoprotein (LDL) cholesterol target <2.6 mmol/ l (100 mg/dl) for patients with coronary heart disease, <3.4 mmol/l (130 mg/dl) for those with two or more risk factors, and <4.1 mmol/l (160 mg/dl) for those with fewer than two risk factors. Moreover, a revision of the guidelines suggested an optional goal of <1.8 mmol/l for patients with coronary heart disease.4 Performance measures have also focused on achieving target levels.5

The approach used by the guidelines is based on the dogma best described by Daniel …

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