Cholesterol confusion in primary prevention of coronary artery disease.

Despite the impressive relation between an increased blood cholesterol and increased mortality from coronary artery disease and despite the persuasive results of cholesterol-lowering trials in secondary prevention, there are increasing reservations about the wisdom of lowering moderately raised blood cholesterol levels in patients who have no symptoms of coronary artery disease. In particular, there are important differences between total mortality and cardiovascular mortality, and between relative and absolute risks. A policy that may be practiced by clinical cardiologists is proposed. In essence, each patient should be assessed for all the chief cardiovascular risk factors in that particular individual. Primary prevention by cholesterol reduction in the absence of symptoms of coronary artery disease requires very careful judgement and should only be undertaken when there is good evidence that the risk of coronary artery disease can be reduced in absolute terms. For primary prevention to be effective requires that the whole gamut of coronary risk factors should be addressed.