Citation

Sleight P. Journal of Vascular Medicine and Biology 1994; 5(3): 125-128.

Copyright

(Copyright © 1994)

DOI

unavailable

PMID

unavailable

Abstract

Since the seminal seven countries study by Keys et al., the cholesterol hypothesis has been amply confirmed despite some discrepancies, particularly within rather than between countries. These variations may be largely explained by differences in other risk factors, notably, the amount of protective antioxidants in the diet and perhaps the protective effect of alcohol. Steinberg et al. suggest that oxidized rather than native LDL cholesterol is recognized by scavenger receptors on the surface of macrophages which then accumulate in the arterial wall and produce plaques. There are skeptics who still question the need to lower cholesterol in the face of the continuing high mortality from coronary heart disease (CHD). Their arguments are based partly on population 'misfits'; partly on the evidence that, although lipid-lowering may reduce CHD death in secondary prevention trials, it has not reduced total mortality; and partly on the evidence that lipid-lowering may increase non-CHD deaths, in particular, by violence, accidents, suicide, and cancer. Trials of modest lipid-lowering (reductions of 10% or less) in middle-aged men (who commonly die of non-CHD causes) need to randomize 700,000-800,000 men and follow-up for at least 5 years to enable detection of an effect on total rather than CHD mortality. In fact, the total numbers in such randomized trials have been too small to answer this question. Larger trials of more potent drugs and with higher-risk patients are now underway. Furthermore, the longest study (10 years) of lipid-lowering so far performed with an approximately 25% reduction in cholesterol showed no excess of cancer, suicide, or violent deaths compared with controls. It is particularly clear (but rarely heeded) that secondary prevention such as after a myocardial infarct is worthwhile, yet many physicians believe it is too late for intervention. Recent angiographic and ultrasound regression trials, however, have given the lie to these prejudices.

Language: en

Keywords

Secondary; Prevention; human; ischemic heart disease; primary prevention; mortality; article; priority journal; antilipemic agent; placebo; secondary prevention; simvastatin; hypertension; ascorbic acid; alpha tocopherol; Primary prevention; beta carotene; Coronary heart disease; Lipid-lowering trials; Total mortality