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Editorial |

Cholesterol-Lowering Therapy for Primary Prevention Still Much We Don't Know

Lee A. Green, MD, MPH
Arch Intern Med. 2010;170(12):1007-1008. doi:10.1001/archinternmed.2010.168.
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In this issue of the Archives, Ray et al1 and de Lorgeril et al2 reignite the long-simmering controversy concerning the use of lipid-lowering therapy for the primary prevention of cardiovascular and cerebrovascular events. Each article provides a different and valuable perspective.

Ray and colleagues present what is to date the cleanest and most complete meta-analysis of pharmacological lipid lowering for primary prevention. Limiting the analysis to patients without existing coronary disease is critical because studies that include both groups of patients may appear to show benefit for all patients, when all the benefit accrues to those with existing disease. The patients in their analysis reduced their average levels of low-density lipoprotein cholesterol from 139 to 98 mg/dL (to convert to millimoles per liter, multiply by 0.0259) and are therefore representative of those being treated in primary care today. The sample size and the number of events were large enough to detect a clinically meaningful effect size, but the authors did not find one for outcomes that were not confounded with medical decision making (and hence susceptible to bias). They caution that their analysis was limited to short-term treatment (averaging <4 years).

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