High Blood Cholesterol and Cardiovascular Deaths in Women

Arecent editorial in Circulation' calls for a "change in direction" of health policy on blood cholesterol. It proposes to "pull back" and "put on hold" the underlying strategy of the present cholesterol control program. The thrust of the editorial is to give up populationwide efforts to achieve, by dietary means, a healthier lifestyle aimed at shifting downward the present too-high cholesterol level. It proposes to abandon efforts to identify in the general population large numbers of people with definite hypercholesterolemia. Instead of the current combined populationwide and high-risk strategy, the editorial urges that the cholesterol control effort be limited to "those with coronary disease or other reasons for being at a comparable very high risk of CHD [coronary heart disease] death." This advice means giving up on primary prevention of CHD and letting stand, for most people, the unfavorable lifestyle patterns-particularly nutritional-that promote atherogenesis and underlie the CHD epidemic. The present national health policy to turn back the coronary epidemic has developed since 1961 and is based on considered and reconsidered assessments of the scientific evidence. Its foundation is the extensive concordant data accrued with use of every research method-animal experimental, pathologic, clinical, and epidemiologic.2-16 The cornerstone of this policy has been improved lifestyles (better nutrition, smoking cessation, and more physical activity). While quantitative estimates of the impact of favorable changes in specific risk factors can be of only limited precision,17-23 it is reasonable to infer that implementing this policyincluding its nutritional recommendations related to serum cholesterol-has contributed to the remarkable 50% reduction in coronary and cardiovascular disease death (CVD) that has occurred since the 1960s and to the years added to life expectancy for adults. This policy to combat the coronary epidemic is apparently a winner. Why then abandon or drastically revise it? The editorial by Hulley et all gives three reasons to justify "put[ting] on hold" this strategy for primary prevention of CHD: (1) an observed "association between low blood cholesterol and noncardiovascular deaths in men and women"; (2) ".... no association between high blood cholesterol and cardiovascular deaths in women"; and (3) in primary prevention trials of cholesterol intervention, observation of ".... an increase in non-CHD death rates that is similar in magnitude to the decrease in CHD death rates."1 Are these claims sound? Are they based on proper assessment of all the data available?