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The role of the elevation of serum cholesterol levels as a cause in the genesis of atherosclerosis and its clinical sequels, mainly coronary heart disease, was well established several decades ago by means of a number of large cohort studies , after cross-sectional studies had shown an association between hypercholesterolemia and ischemic heart disease. Ever since, the acknowledgement of this role has encouraged many randomized studies designed to test the hypothesis that the lowering of cholesterol levels might bring about a reduction in morbidity and mortality caused by cardiovascular disease. Over the last few years, a number of such studies have shown an important decline in the incidence of ischemic heart disease events, and some of them have shown that with the use of statins a reduction in both cardiovascular disease and total mortality occurrs . Based on these findings, it became a consensus among cardiologists that a need existed to increase the prescription of drugs to lower cholesterol levels. Several papers have reported concern about the small use of these drugs and the resulting damage suffered by patients who do not receive this treatment , even in the USA and in Europe. In Great Britain, a recent study showed that only in 17% of patients with indication of secondary prevention presented lipid concentrations, according to the official guidelines . In our environment, the situation is more critical yet, because the socioeconomic situation in Brazil prevents the correct use of statins, even when the cardiologists are absolutely sure about its indication. With the purpose of drawing attention to the need for carrying out a nationwide cost-effectiveness study concerning the use of statins in primary and secondary prevention, we made a descriptive cost analysis of these drugs, in relation to the benefits they bring about, based on the large randomized clinical trials of primary and secondary prevention. In the cost-effectiveness ratio of an intervention, the absolute risk reduction is more important than the relative reduction obtained. The absolute benefits of the treatment tend to be greater and the cost-effectiveness ratio more favorable in groups of patients at higher absolute risk . Thus, at the beginning, a greater absolute benefit and a better cost-effectiveness ratio are expected in secondary prevention, as compared with that in primary prevention. Moreover, even considering the primary and secondary prevention groups separately, within each one of them, higher risk patient groups like those with lower HDL-cholesterol levels, a higher total or LDL-cholesterol level, older age, or history of diabetes or smoking, have a higher risk and consequently a greater absolute benefit for the same relative risk reduction . This means that, even though the relative benefit may be similar for different initial risk levels, a greater absolute benefit, and a better cost-effectiveness ratio in the groups at higher risk will exist. Looking at the issue from this angle, we can predict a better cost-effectiveness ratio in the studies on secondary prevention – Scandinavian Simvastatin Survival Study (4S) , Cholesterol and Recurrent Events Trial (CARE) , and Long-Term Intervention with Pravastatin in Ischaemic Disease Study (LIPID) 8 – than in those on primary prevention – West of Scotland Coronary Prevention Study (WOSCOPS) 5 and Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS) . In the primary prevention group, the WOSCOPS 5 analyzed patients at higher risk (men with total cholesterol above 252mg/dL and mean total cholesterol of 272mg/dL) than the AFCAPS/ TexCAPS 7 (men and women with total cholesterol ranging from 180 to 264mg/dL, HDL-cholesterol below 45mg/dL in men and 47mg/dL in women, and mean total cholesterol of 221mg/dL). In the secondary prevention studies, the profile of patients in 4S 4 (men and women after an acute myocardial infarction or unstable angina with total cholesterol between

How much do we pay for a benefit? A descriptive cost analysis of the use of statins. The need for a national cost-effectiveness analysis