Cholestanol and survival with simvastatin: the missing link
Miettinen and colleagues present an interesting analysis of Finnish patients in the Scandinavian Simvastatin Survival Study, identifying a subgroup with high cholestanol ratios who gained no benefit from statin treatment (1). They suggest that such patients have a low rate of cholesterol synthesis but a high rate of cholesterol absorption and that, as a consequence, drug therapy that blocks the synthesis of cholesterol does not improve survival. Surprisingly they presented no data on the falls in serum cholesterol observed with simvastatin treatment within each cholestanol quartile. This information is surely essential to fully understand the link between high cholestanol ratio and the reduced relative risk reduction with simvastatin. It would also be of interest to know whether the balance between cholesterol absorption and synthesis as measured by the cholestanol ratio accounts for a major part of the large variability between patients in the response of serum cholesterol to simvastatin.
The authors do not comment on the relatively low 21% relative risk reduction by simvastatin in the Finnish patients. This seems much smaller than the 34% risk reduction seen in all 4S patients (2). Is this due to the different definition of major coronary events used in this analysis or did Finnish patients do less well than those in other countries?
Authors E J Wallis
L E Ramsay
W W Yeo
P R Jackson
1. Miettinen TA, Gylling H, Strandberg T, Sarna S for the Finnish 4S Investigators. Baseline serum cholestanol as predictor of recurrent coronary events in subgroup of Scandinavian simvastatin survival study. Br Med J 1998;316:1127-1130.
2. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994;344:1383-1389.
Competing interests: No competing interests