[The treatment of hypercholesterolemia in primary and secondary prevention]

While a number of very effective dietary and pharmacological treatments are now available for the management of hypercholesterolemia, whether the significant and protracted lowering of cholesterolemia brings about a decline not only in vascular disease but also in overall mortality is still unclear. Meta-analysis studies have generally confirmed that "secondary" preventive treatment is highly effective in reducing total and coronary mortality (risk reduction of 3.2% vs only 0.1% in the case of "primary" prevention). However, more recent data underscore that continued pharmacological treatment, which can reduce cholesterolemia for a period of at least 1.5-2 years, may bring the patient back to a lower risk category, thus leading to a decline not only in coronary, but also in total mortality. In support of this conclusion are data from pharmacoeconomic studies from which, by taking as a reference the mean yearly cost of kidney dialysis, even in a low risk subject (50-year-old male without other vascular risk factors), the cost of life saved per year is about half the mean cost of dialysis. Lastly, comparative studies among different therapies indicate that in the majority of cases, treatment that reduces cholesterolemia more than 20% is not absolutely necessary, thus allowing the use of newer, lower cost drugs, some of which, e.g. fluvastatin, may require less intensive toxicologic monitoring in the clinic.