Cholesterol Levels Should Play a More Important Role in Identifying Statin Recipients

Opposing Viewpoint, see p 630 Recent recommendations for statin treatment1,2 have departed from earlier clinical guidelines for cholesterol lowering.3 According to the authors of these new recommendations, the reason for their approach is that it is closest to the randomized clinical trial evidence. However, that opinion lacks circumspection. Greater recognition should have been given to the absolute decrease in low-density lipoprotein cholesterol (LDL-C) as a major determinant of the achievable reduction in cardiovascular disease (CVD) risk.4,5 We do not dispute that the new recommendations are a great advance in statin treatment for people with high absolute CVD risk but whose cholesterol is below average. Many patients, however, encountered in practice with higher LDL-C are badly served by the new guidance, which ironically favors people with low LDL-C above those with higher levels.The 26 statin randomized clinical trials used drugs of differing potencies in various doses and thus each trial produced a different degree of lowering of absolute LDL-C concentration, such that in meta-analysis it is clear that the decrease in CVD incidence relative to control (placebo or in a few trials vs less intensive statin therapy) is related to the mean LDL-C differences between active treatment and control achieved.4 Overall for each 1 mg/dL reduction in LDL-C, the CVD risk decreases to 0.9936 …