Cholesterol, statins and CHD prevention

The BNF back pages cover the Joint British Societies guidance on CHd risk assessment in a way that is easy for me to understand and easy for me to use when I talk to my patients about their CHD risk. So what's the problem?

A recent spate of BMJ articles have given me cause to wobble. Ravnskov in BMJ 2006;332;1330-1332 opens up the debate. The controversy is that if docs were to follow the American National Cholesterol Education Program guidance then 85% of Norwegian men and 20% of the women would be classified at high risk and therefore to be treated with statins. Ravnskov points out that stain safety at the very high doses required to achieve the new targets is uncertain. It is stated that very high dose atorvastatin (80mg daily) doesn't necessarily achieve target lipid levels and is not associated with reduced mortality, moreover more than half of patients suffered some side effects.

Responding letters in subsequent issues of the BMJ make the point that there is some evidence that more aggressive treatment of high risk patients reduces risk of chd at the expense of myopathy and liver disorder.

I conclude that we need to balance our enthusiasm for aggressive treatment of lower risk patients against the potential costs, to the patient and the NHS finances.