The emerging role of statins in the prevention of coronary heart disease

Statins are effective but we need better ways of assessing risk

The Standing Medical Advisory Committee guidelines for the use of statins have ignited considerable debate in Britain, and similar discussions about the use of statins are, or soon will be, occurring in other countries. The crux of the controversy lies, on the one hand, in earnest efforts to prevent coronary heart disease by any effective means available and, on the other, in fiscal realism. Such controversy has been foreseeable since publication of three clinical trials showing that statins are highly effective in preventing heart disease. The British guidelines conservatively recommend statin treatment only for individuals with at least a 3% annual risk of coronary heart disease events—a threshold selected to minimise costs and focus on patients at highest risk. Ironically, the subsequent BMJ editorial criticised the guidelines for being fiscally irresponsible,1 whereas other issued guidelines and much of the journal correspondence2 call for the treatment of more, not fewer, individuals.3

Three interrelated challenges confront efforts to determine the optimal use of statins: (a) sufficient definition of the benefits, costs, and risks of treatment based on data from randomised clinical trials; (b) innovative strategies to minimise treatment costs; and (c) improved methods for estimating individual patients' risk. It is now clear that treatment of hypercholesterolaemic patients with statins reduces the incidence of fatal and non-fatal myocardial infarctions by 30-35%.4 These benefits are accompanied by fewer coronary revascularisation procedures and …