Targeted versus global approaches to the management of hypercholesterolaemia.
OBJECTIVE
The role of statins in secondary prevention of cardiovascular disease is well established. However, there is debate about the most effective approach to primary prevention. This study simulated the effects of directed versus global approaches for intervention on coronary heart disease (CHD) event rates.


METHODS
A primary prevention population was generated by computer simulation derived from data from the National Health Survey for England. The efficacy of reductions in cholesterol, treatment to cardiovascular risk targets and effects of phytosterols or statins were assessed.


RESULTS
A 0.5 mmol/L reduction in population total cholesterol would result in a 10.4% reduction in CHD events, while 1.0 mmol/L, 1.5 mmol/L and 2.0 mmol/L reductions would achieve 21.0%, 30.6% and 41.9% reductions respectively. In statin-based cardiovascular risk targeted strategies, use of simvastatin 40 mg would result in 1.8% reduction by UK National Service Framework targets of 30%/decade CHD risk and 7.2% reduction in events for a 20%/decade target assuming perfect adherence. Similarly, aggressive primary prevention with 40 mg atorvastatin would result in a 2.5% or 10% reduction in events. Universal use of 10 mg simvastatin following an over-the-counter approach would result in a 25% reduction in CHD events. In contrast, whole population consumption of sitostanol/sitosterol products would result in 11.8% reduction.


CONCLUSIONS
Targeting and treating high-risk individuals may be beneficial for them and rewarding for medical practitioners. However, this approach has minimal effects on the population burden of atherosclerotic disease. This study suggests that universal therapy with phytosterols and/or wider availability of statins has the potential to dramatically decrease rates of CHD.
Reynolds
Timothy M
TM
Clinical Chemistry Dept, Queen's Hospital, Belvedere Road, Burton-on-Trent, Staffordshire DE13 0RB, UK., tim.reynolds@burtonh-tr.wmids.nhs.uk
Mardani
Alireza
A
Twomey
Patrick J
PJ
Wierzbickid
Anthony S
AS
D000924:Anticholesteremic Agents / Q000191:economics / Q000600:supply & distribution / Q000627:therapeutic use*; D002784:Cholesterol / Q000097:blood; D003198:Computer Simulation; D003327:Coronary Disease / Q000191:economics / Q000517:prevention & control*; D003362:Cost-Benefit Analysis; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000191:economics / Q000600:supply & distribution / Q000627:therapeutic use*; D006937:Hypercholesterolemia / Q000188:drug therapy*; D004366:Nonprescription Drugs; D010840:Phytosterols / Q000191:economics / Q000627:therapeutic use*; D011322:Primary Prevention / Q000379:methods*; D012307:Risk Factors
D000924:Anticholesteremic Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D004366:Nonprescription Drugs; D010840:Phytosterols; D002784:Cholesterol