to the editor of JAMA
With their new guidelines the National Cholesterol Education Program’s (NCEP) expert panel1 exaggerates the risk of coronary heart disease (CHD) and the relevance of high cholesterol and ignores a wealth of contradictory evidence. A few examples.
To claim that 20% of patients with coronary heart disease have a new heart attack after ten years the panel has included minor symptoms without clinical significance. Most people survive even a major heart attack, many with few or no symptoms after recovery. What matters is how many dies and this is much less than 20%.
predictive power of a high cholesterol is overrated. In the 30 year follow-up of
the Framingham cohort for instance, high cholesterol was not predictive after
the age of forty-seven.2
It is not a strong predictor for women, Canadian men and patients with
established CHD either. In Russia, low cholesterol is a predictor of CHD2
and individuals with familial hypercholesterolemia may live just as long and
have a risk of CHD just as low as that of normal people.3
No doubt the statins lower coronary mortality, but the size of the effect is unimpressive. In the CARE trial for instance, the odds of escaping death from a heart attack in five years for a patient with CHD was 94.3%, which improved to 95.4% with statin treatment. For healthy people with high cholesterol the effect is even smaller; in the WOSCOPS trial, the figures were 98.4% and 98.8%, respectively. These figures do not take into account possible side effects which usually appear more often. In animal experiments the statins have proven carcinogenic. In the CARE trial statin treatment was followed by more breast cancer. In the EXCEL trial, total mortality after just one year was much higher in those receiving statins. Unfortunately the trial was stopped before further observations could be made.2 We need more experience before introducing mass-prevention with potentially carcinogenic drugs.
panel ignores that a systematic review of relevant epidemiological and
experimental studies found no evidence that dietary fat has effect on
atherosclerosis and cardiovascular disease.4 Most important, coronary
and total mortality were unchanged in meta-analyses of the dietary trials.4
of preventing cardiovascular disease the new guidelines may transform healthy
individuals into unhappy hypochondriacs obsessed with the chemical composition
of their food and their blood, destroy the art of cuisine and the joy of eating,
and divert health care money from the sick and the poor to the rich and the
the editor's answer below
October 1, 2001
October 1, 2001