The United Kingdom is 10 to 20 years behind the rest of Europe and the United States in its use of lipid lowering drugs. In 1998, in England, 2.2 per cent of adults were taking these drugs. "This is an example of appalling therapeutic nihilism," said Professor Neil Poulter (professor of preventive cardiovascular medicine, Imperial College school of medicine, London) last week, pointing out that the UK had one of the highest rates of coronary heart disease (CHD) mortality worldwide.
Professor Poulter was speaking at the 5th Cardiovascular Disease Prevention conference, in London, on April 5. He said that arguments put forward for not using statins - despite compelling evidence of their benefits - included the suggestion that the long-term effects of the drugs were not known and that cholesterol was not an important risk factor for CHD unless other risk factors co-existed. But these points were no more applicable to hyperlipidaemia than to hypertension or to diabetes. In his view, the major current excuse for inertia was cost. "Low use of statins is completely cost driven."
Professor Poulter said that it was important to start using statins for all patients with CHD as secondary prevention and in "high risk" patients as primary prevention.
Dr Martin Cowie (senior lecturer in cardiology, University of Aberdeen) said that there was more evidence for the cholesterol hypothesis "than for nearly any other medical belief." Although some "fine tuning" was still needed regarding use of statins (eg, what age to start and stop treatment, whether to aim for a target concentration or for a percentage reduction in LDL, which drug to use, and how soon to start a statin after a myocardial infarction), there was already clear evidence from randomised trials of the benefit of using the drugs to reduce LDL-cholesterol and reduce cardiac risk in both primary and secondary prevention. "The challenge now is implementation," he said.
On the question of the upper age limit for using statins, Dr Cowie said that data from randomised trials only existed up to age 75 "but if [an older] patient is fit enough to be seen by me at the clinic, they are fit enough to be given the benefit of the doubt on treatment."
The new National Service Framework for CHD recommends use of statins to lower serum cholesterol to less than 5mmol/L or by 30 per cent (whichever is the greater).
Professor Poulter said that a trial was needed to assess different target cholesterol levels. His view was "the lower the better" but there was no science to back this. That said, if a patient had had an MI, their cholesterol level was too high, whatever it was. Dr Cowie said that the current targets were important. "We've got to be pragmatic - we need targets to judge how well we are doing and to change practice." There was a long way to go to reach even the "modest targets" in the NSF guidelines. "A lot of places have not even sorted out secondary prevention yet," he said.
Professor Poulter suggested that, in the future, the statins might be able to be made available for over-the-counter sale. They were well tolerated compounds. He accepted the argument that only certain groups of patients would be able to afford to buy the drugs but suggested that this was not necesarily a bad thing if, overall, it meant that more people would get the drugs. "I am concerned about the number of people with coronary artery disease who are dying because they are not getting statins," he said.