[Cholesterol: blood levels or total risk as a guide to preventive treatment?]

The results of a cholesterol lowering therapy with statins do belong to the best documented steps in medical treatment. The newer studies like HPS and LIPID have shown a therapeutic benefit across all serum-cholesterol levels, nearly obviating the need for a prior determination of the cholesterol values. Why not using the serum-cholesterol level as the only guide to therapy? Since there is no threshold indicating the need for treatment, there is the danger of an unlimited inflation of the indications for therapy, possibly leading to a collapse of the health care system. At the upper extreme, therapy would have to start at a very young age, and no one can predict the side effects of a statin therapy over many decades. Improving the target for therapy can only be achieved via determination of the total risk of cardiovascular disease. Several algorithms like PROCAM ( www.chd-taskforce.de), the risk chart of the European Society of Cardiology or the Framingham risk-scores will come to similar results. In this manner, one can differentiate further, and persons with a low risk of cardiovascular disease like women and young adults do not have to be treated unnecessarily. However, it must not be overlooked that the sensitivity of these risk-scores is rather low. The majority of myocardial infarctions occur in the average risk population, because of sheer numbers. Independent indicators of cardiovascular risk, such as the CRP, the intima-media thickness of the carotid artery and in particular the determination of the coronary calcium score via EBT or ultrafast scan can lead to more clarity. To improve the estimation of the individual risk, we will need a combination of risk-factors and -indicators.