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Lowering Risk without Lowering Cholesterol: Implications for National Cholesterol Policy

Andrew L. Avins, MD, MPH; and Warren S. Browner, MD, MPH
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From the Veterans Affairs Medical Center and the University of California, San Francisco, San Francisco, California. Grant Support: In part by grants HL51024 and HL46297 from the National Heart, Lung, and Blood Institute. Requests for Reprints: Andrew L. Avins, MD, MPH, General Internal Medicine Section, 111A1, Veterans Affairs Medical Center, 4150 Clement Street, San Francisco, CA 94121. Current Author Addresses: Drs. Avins and Browner: General Internal Medicine Section, 111A1, Veterans Affairs Medical Center, 4150 Clement Street, San Francisco, CA 94121.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1996;125(6):502-506. doi:10.7326/0003-4819-125-6-199609150-00012
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Current recommendations for the treatment of hypercholesterolemia include drug therapy for persons at sufficiently elevated risk for coronary heart disease.However, no guidelines incorporate the effects of alternative interventions that decrease risk for coronary heart disease but are not used specifically to alter blood lipids.

We did a simulation study to estimate the number of hypercholesterolemic adults who would continue to exceed a high-risk threshold after receiving aspirin, antihypertensive medication, and estrogen-replacement therapy. We found that of all persons who are currently candidates for hypolipidemic medication because they are at high risk for coronary heart disease, 6 to 8 million would no longer have this therapy recommended if the abilities of alternative interventions to reduce risk were considered. Pharmaceutical cost savings associated with alternative interventions range from $3 to $4 billion per year. Current guidelines should be revised to account for this effect.


Grahic Jump Location
Figure 1. Comparison of risk before use of an alternative intervention (solid line), after aspirin therapy ( ), and after aspirin, antihypertensive, and estrogen-replacement therapies ( ).
Number of hypercholesterolemic adults who exceed any risk threshold for coronary heart disease.dashed linedotted line
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