Primary prevention of coronary heart disease: role of cholesterol control in the United States

The benefit of cholesterol-lowering drug therapy in patients with existing coronary heart disease (CHD) is well established through clinical trials. Prevention of recurrent coronary morbidity and mortality in CHD patients is called secondary prevention. In contrast, primary prevention is delaying or preventing altogether new-onset-CHD. There are three categories of primary prevention: high-risk, moderate-risk, and long-term (life-time). A recent clinical trial has documented benefit of cholesterol-lowering drugs for prevention of coronary morbidity and mortality and total mortality in hyper-cholesterolemic, middle-aged men. This trial lends support for including aggressive cholesterol reduction in high-risk primary prevention. However, for such therapy to be cost effective at present-day prices of cholesterol-lowering drugs, only those patients in the higher ranges of risk can be selected for treatment. This leaves a large number of people at moderately high risk for premature CHD because of high cholesterol levels. These persons deserve increased professional attention to risk reduction. In general the nondrug approach is indicated. The latter approach includes eliminating other risk factors, e.g. cigarette smoking and hypertension, and reducing serum cholesterol levels by decreased intakes of saturated fatty acids, cholesterol, and excess total calories. Some moderate-risk patients may require low doses of cholesterol-lowering drugs to achieve the goals for cholesterol reduction. Finally, public health strategies need to be developed for applying the same nondrug approach for the general population for reducing the overall incidence of CHD.