[The cholesterol controversy]

"Leave well enough alone" might be one's conclusion after rereading all the cholesterol lowering trials. We have tried to lower serum cholesterol below 2 g/l in all subjects in order to eliminate the lipid effect in the atherogenesis process. But some metaanalyses have shown that when cholesterol falls below 1.6 g/l overall mortality rises. There is some controversy over these findings but it can be stated that when cholesterol level fall below a certain threshold, it looses its capacity to mark for cardiovascular risk and becomes an interesting indicator of a patent or infraclinical disease state. If we consider the relationship between the whole range of cholesterol levels and risk of morbidity and mortality, the data draw a J curve with a nadir somewhere between 1.8 and 2 g/l. Minimal risk appears to lie between tolerance limits situated at 1.6 and 2.2 g/l. There is no real contradiction between the results of prospective cholesterol lowering trials and the emphasis placed on the danger of cholesterol levels below 1.6 g/l. In fact the objective must be to maintain serum cholesterol at the lowest risk level both in terms of coronary artery disease (as many as 25% of coronary deaths can be prevented according to the most recent metaanalyses) and in terms of overall mortality (cancer, suicide, and even murder). The questions and doubts raised by the tendancy for increased risk on the lower end of the J curve should not change our objective of fighting against hypercholesterolaemia.