Selections from current literature: the cholesterol controversy

This issue of 'Selections' focuses on studies of cholesterol reduction in asymptomatic adults. Treatment of persons with coronary heart disease involves other issues and the need to consider additional evidence from other studies. Elevated blood cholesterol levels are associated with increased coronary heart disease in young adults. The real question is whether or not lowering cholesterol levels with diet and drugs is possible and if possible, whether it reduces the risk of morbidity and mortality. Even if the relative risk can be reduced it is necessary to consider the absolute risk reduction. Reduction of the risk of fatal myocardial infarction from 2.0% to 1.6% over a seven year period while at the same time increasing the risk for gallbladder surgery from 1.3% to 1.9% may not be an attractive gamble. There is little evidence that elevated cholesterol levels are a risk factor in adults over the age of 60 years. Intervention trials have not been conducted in women or in the aged, and overall mortality has not been reduced in any of the studies. The Department of Health and Human Services of the United States recommends an approach that if implemented could have initial costs that exceed 10 billion dollars. Yearly costs are likely to exceed the initial cost. In a recent editorial Professor Joseph Herman expresses concern that the Israel Society for Research on Atherosclerosis and the European Atherosclerosis Society have adopted similar recommendations to those recently announced in the United States. He also points to large variations reported from 5000 laboratories given standard samples to be tested for total cholesterol. Currently blood cholesterol levels are available to shoppers at a supermarket in Florida (New York Times 1989, January 3). The end of this controversy is not yet in sight.