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Clinical Decisionmaking

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Cholesterol reduction guidelines for primary prevention should complement more effective secondary prevention efforts

The National Cholesterol Education Program (NCEP) clinical guidelines for screening and treating elevated cholesterol levels are rapidly becoming the standard of care in the United States. However, secondary prevention—that is, reducing cholesterol levels among men and women who already have coronary heart disease—is more effective than preventing elevated cholesterol levels in people without coronary artery disease (primary prevention). Thus, NCEP primary prevention guidelines should complement the more appealing strategies of secondary prevention, concludes a study supported by the Agency for Healthcare Research and Quality (HS06258).

Milton C. Weinstein, Ph.D., of the Harvard School of Public Health, and colleagues used a simulated model of the U.S. population, aged 35 to 84 years, to estimate the potential for the NCEP guidelines, under varying assumptions, to reduce coronary heart disease morbidity and mortality and overall mortality from the years 2000 to 2020. They calculated that primary cholesterol prevention efforts would yield only about half of the benefits of secondary prevention, despite requiring nearly twice as many person-years of treatment. Also, the projected increase in quality-adjusted years of life per year of treatment for secondary prevention was 3- to 12-fold higher than for primary prevention.

The larger benefits of secondary prevention are due to the higher risks of men and women who already have coronary heart disease and the more aggressive goal of LDL cholesterol reduction for this group. Their annualized risk of death due to coronary heart disease is 10 percent to 130 percent higher in women and 15 to 50 percent higher in men compared with high-risk and medium-risk women and men without coronary heart disease who are 30 years older. Annualized risks for heart attacks follow a similar pattern. The LDL cholesterol reduction goal for secondary prevention (100 mg/dl) is much greater than for high-risk primary prevention (130 mg/dl) or medium-risk primary prevention (160 mg/dl).

Details are in "The relative influence of secondary versus primary prevention using the National Cholesterol Education Program adult treatment panel II guidelines," by Lee Goldman, M.D., M.P.H., Pamela Coxson, Ph.D., Maria G.M. Hunink, M.D., Ph.D., and others, in the September 1999 Journal of the American College of Cardiology 34(3), pp. 768-776.

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