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The Association between Cholesterol and Death from Injury

Peter Cummings, MD, MPH; and Bruce M. Psaty, MD, PhD
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From the University of Washington School of Public Health and Community Medicine and School of Medicine, Seattle, Washington. Requests for Reprints: Peter Cummings, MD, Harborview Injury Prevention and Research Center, 325 Ninth Avenue, ZX-10, Seattle, WA 98104. Grant Support: In part by R49/CCR002570 (Centers for Disease Control and Prevention). Dr. Psaty is a Merck/Society for Epidemiologic Research Clinical Epidemiology Fellow (sponsored by the Merck Company Foundation, Rahway, New Jersey, and the Society for Epidemiologic Research, Baltimore, Maryland).

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1994;120(10):848-855. doi:10.7326/0003-4819-120-10-199405150-00006
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Purpose: To review the association between low serum cholesterol and death from injury.

Data Sources: Relevant English-language papers identified through MEDLINE and Current Contents searches and bibliographies of identified articles.

Study Selection: More than 150 articles were reviewed to identify data, meta-analyses, or important reviews of the association between low cholesterol and injuries.

Data Extraction: Estimates of the association between cholesterol and death from injury were extracted from published reports.

Data Synthesis: Animal studies and descriptive studies have provided little information about serum cholesterol and injuries. The Conference on Low Blood Cholesterol pooled results from 14 cohort studies in men and found a relative risk of 1.4 for death from injury in men whose cholesterol levels were lower than 4.14 mmol/L (160 mg/dL) compared with men whose cholesterol levels were 4.14 to 5.15 mmol/L (P = 0.003). Most cohort studies support this finding. The strongest evidence that cholesterol and death from injury are related comes from a meta-analysis of six randomized cardiac primary prevention trials of cholesterol reduction; the relative risk for death from injury for treated men compared with controls was 1.42 (95% CI, 0.94 to 2.15).

Conclusions: In cohort studies, the strength of the association between low serum cholesterol levels and subsequent death from injury is weak and may be caused by confounding factors such as socioeconomic status. The modestly elevated risk ratio found in a meta-analysis of trials of cholesterol reduction in men is of borderline statistical significance. This association may be related to efforts to lower cholesterol rather than to low absolute levels of serum cholesterol. Until more data are available, the hypothesized relation between low cholesterol and injuries remains unsettled.


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Figure 1.
Relative risk estimates and 95% confidence intervals for death from injury of treated patients compared with controls in cholesterol-lowering trials.

Relative risk greater than 1.0 indicates that cholesterol reduction increases the risk for death from injury. The reference number is given for individual studies; the number of studies used is given for summary estimates. Studies marked with an asterisk had relative risk estimates of infinity. Studies with no deaths from injury are not illustrated (references 49, 62, 70, 72, 78, 85), although they are included in summary estimates. WHO = World Health Organization; LRC = Lipid Research Clinics; MRFIT = Multiple Risk Factor Intervention Trial; CDP = Coronary Drug Project; POSCH = Program on the Surgical Control of Hyperlipidemia.

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