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Individual patient factors determine whether a special diet or medication is best for patients with high cholesterol

The National Cholesterol Education Program (NCEP) recommends treatment guidelines for primary prevention (no history of coronary heart disease, CHD) and secondary prevention (history of CHD) based on cholesterol level and number of risk factors.

According to the NCEP guidelines, patients in the primary prevention group should be treated as follows:

  1. Dietary therapy for all patients with LDL greater than 160 mg/dL.
  2. Drug treatment (using a statin) concurrent with dietary therapy for patients whose LDL is above 190 mg/dL, regardless of risk profile.
  3. Drug therapy concurrent with dietary therapy for patients who have two or more risk factors and an LDL of 160-189 mg/dL.

NCEP guidelines for secondary prevention include drug treatment concurrent with diet therapy for all patients whose LDL is higher than 130 mg/dL, regardless of risk profile. However, these recommendations are based on average patient characteristics and may be misleading when used in individual treatment decisions, note the authors of a recent study.

Their research suggests that primary prevention with diet for otherwise healthy young women may not be a cost-effective option, and that primary prevention with a statin may not be cost effective for some risk subgroups. However, their findings do agree with the NCEP that use of a statin for secondary prevention in all risk subgroups is cost effective. The study was supported in part by the Agency for Healthcare Research and Quality (HS06258, principal investigator Milton C. Weinstein, Ph.D., of the Harvard School of Public Health). The researchers used a computer simulation model to estimate the effects and costs of cholesterol-lowering diet or statin drugs in each risk group.

Diet therapy for primary prevention was generally cost effective, with cost-effectiveness ratios generally less than $100,000 per quality-adjusted life year (QALY) for men and women with more than one risk factor, except for some women under 45 years of age. Cost-effectiveness ratios for primary prevention with a statin varied widely according to risk factor subgroup, from $54,000 per QALY to $420,000 per QALY for men and from $62,000 per QALY to $1,400,000 per QALY for women, and were greater than $100,000 per QALY for many risk subgroups. Secondary prevention with a statin was cost effective for all risk groups, with cost-effectiveness ratios of less than $50,000 per QALY for all risk subgroups and only $10,000 per QALY or less for most risk subgroups. In general, most cost-effectiveness ratios became more favorable with increasing numbers of risk factors. However, certain risk factors, such as high diastolic blood pressure, had more impact than others.

See "Cost-effectiveness of cholesterol-lowering therapies according to selected patient characteristics," by Lisa A. Prosser, M.S., Aaron A. Stinnett, Ph.D., Paula A. Goldman, M.P.H., and others, in the May 16, 2000 Annals of Internal Medicine 132(10), pp. 769-779.

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