Health in Europe—a view from across the Atlantic

www.thelancet.com Vol 381 April 13, 2013 1257 From a North American perspective, it is irresistible to extend cross-national comparisons from The Lancet Series on Health in Europe to include the USA, particularly in light of a 2013 US National Research Council and Institute of Medicine (NRC/IOM) report showing that, for most health indicators and all ages to 75 years, the USA ranks worst or among the worst of 17 similarly affl uent countries (including 15 in western Europe). The US health disadvantage was noted across diverse indicators including life expectancy (fi gure); prematurity and low birthweight; infant, child, and maternal mortality; incidence of and mortality from Health in Europe—a view from across the Atlantic Although not the focus of the study, Talmud and colleagues show that even a diagnosis of a major mutation in familial hypercholesterolaemia does not always result in appropriate LDL-C treatment; the mean LDL-C concentration after treatment was only reduced by 22%, to 5·49 mmol/L (recommended goal <2·6 mmol/L). Even in the mutation-negative cohort, with lower starting LDL-C concentrations, the mean post-treatment concentration was 4·22 mmol/L, a reduction of only 28%. These results, from patients attending specialised lipid centres, are a cause for concern, especially as highly eff ective statins that lower LDL-C in patients with familial hypercholesterolaemia by 50% are now generic and inexpensive. Randomised trials have shown that the more LDL-C is lowered, the lower the risk for coronary artery disease. Findings from Mendelian randomisation studies show that polymorphisms associated with lower LDL-C starting presumably in childhood are associated with a far greater reduction in the risk of coronary heart disease than is reported in drug trials beginning later in life, after atherosclerosis has already developed. Thus all people, irrespective of age, with raised LDL-C concentrations in whom no secondary cause can be identifi ed, especially if they have a family history of premature coronary artery disease, should be treated for presumptive familial hypercholesterolaemia according to clinical criteria. To add the complexity of SNP analysis for minor genes and eliminate cascade LDL-C and clinical testing of relatives of patients with polygenic familial hypercholesterolaemia does not seem to be warranted, and could even be diversionary.