William E. Cayley, MD, MDiv
Potential Financial Conflicts of Interest: None disclosed.
Cayley W.; Monitoring Cholesterol Levels: Understanding Variance and Finding the Most Useful Data. Ann Intern Med. 2008;149:436-437. doi: 10.7326/0003-4819-149-6-200809160-00018
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Published: Ann Intern Med. 2008;149(6):436-437.
TO THE EDITOR:
The study by Glasziou and colleagues (1) finds that “noise” random variations during serial cholesterol level monitoring may be greater than the change in cholesterol levels due to a therapeutic effect. This points to the importance of what exactly has been tested in cholesterol-lowering studies. Although guidelines and clinical practice often focus on titrating lipid treatment to obtain specified goal levels (2), the intervention that has actually been tested in many of the important statin trials is the administration of a fixed medium or high dose of a cholesterol-lowering medication. For example, the WOSCOPS (West of Scotland Coronary Prevention Study) and LIPID (Long-Term Intervention with Pravastatin in Ischaemic Disease) studies compared pravastatin, 40 mg/d, with placebo (3, 4), and the PROVE-IT (Pravastatin or Atorvastatin Evaluation and Infection Therapy) and REVERSAL (Reversal of Atherosclerosis with Aggressive Lipid Lowering) studies compared fixed high-dose atorvastatin with fixed medium-dose pravastatin (5, 6). Thus, the treatment that has been evaluated in each case is a fixed dose of a cholesterol-lowering medication, not titration to a specified goal. Evidence-based cholesterol treatment should then focus on providing patients with an appropriate statin dose based on trial data rather than on a less-studied dose-titration strategy.
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