Cholesterol reduction: what can we afford?

In this issue van Hout and Simoons describe a cost-effectiveness analysis of cardiovascular disease risk reduction by HMG coenzyme reductase inhibitors (statins). This exercise stems from the recommendations of the Netherlands Consensus Committee on Lipid Lowering. Costs of prescriptions and of major medical events (death, acute myocardial infarction, stroke, PTCA and CABG surgery) are considered. At an estimated cost of Euro 18 000 per year of life gained, the authors suggest that statin treatment be considered for secondary prevention in most patients with known cardiovascular disease, and for primary prevention among a limited group of patients. They estimate that 1·8% to 3·4% of the Netherlands population would be eligible for treatment under these guidelines. This thorough analysis provides more data to inform the debate on the treatment and prevention of cardiovascular diseases. As the authors recognize, cost analyses, in general, and the analyses in this study, have limitations. Generalizing from clinical trials to a national population requires assumptions that may not be well founded. Trials may be limited in gender, race and age distributions, requiring extrapolation and imputation from known information. In this study, the authors limit the cost data to medications and hospital charges. This ignores both individual and societal costs of illness. For an individual, the pain, emotional anguish and disability associated with a chronic disease is crucial but difficult to quantify in monetary terms. For society, the loss of a productive member due to chronic illness and the associated economic costs of care outside of the hospital should also be considered. Including these considerations would add to the ‘effectiveness’ side of the equation. The advent of the statin drugs for lipid lowering contributes a new dimension to the treatment and prevention of cardiovascular diseases. Statins have been extensively evaluated in large clinical trials and shown to be highly beneficial in lowering coronary heart disease, stroke and overall mortality associated with the lowering of LDL cholesterol. This benefit