TO THE EDITOR: the article onward ...

TO THE EDITOR: the article onward cholesterol abnormalities by Lockman and colleagues in the March 15 2005 issue of American Family Physician does not address the uncertain efficacy of statins for the primary prevention of cardiovascular disease in women and older patients.

Evidence for the efficacy of statins for primary prevention in women is limited. the investigation populations of the three major primary prevention trials (1-3) cited by way of Lockman and colleagues consisted of 0 15 and 19 percent women respectively, and primary issues were not statistically significant in women A meta-analysis (4) showed no statistically significant result of lipid-lowering treatment in primary prevention in women the authors conclud that although the summary estimate give an inkling ofs a reduction in coronary heart disease (CHD) affairs the small number of occurrences limits the ability to draw conclusions about the loyal effect. (4)

The National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP-III) (5) recognizes the uncertainty concerning the efficacy of statins in primary prevention in women It states that for women in the moderate risk category (10-year risk equivalent of 10 to 20 percent) "clinical trials of [low-density lipoprotein] LDL-lowering generally are lacking [for women with at least sum of two units risk factors]; rationale for therapy is based upon extrapolation of benefit from men of similar risk." (5) Because heart disease may be different in women and men we question whether this extrapolation is valid.

Similarly, there are scarcely any studies and inconclusive results for primary prevention in patients at least 65 years of age. The major primary prevention studies provide little information. The West of Scotland Coronary Prevention inquiry group (WOSCOPS) (1) excluded patients older than 65 years at enrollment The Air Force/Texas Coronary Atherosclerosis Prevention cogitation (AFCAPS/ texCAPS) (2) reported terminates by median age (at least 57 years in men and 62 years in women) and did not not absent data that can be interpreted for those 65 years or older the Anglo-Scandinavian Cardiac results Trial-Lipid Lowering Arm (ASCOT-LLA) (3) reported using an age cutoff of 60 years. the Prospective cogitation of Pravastatin in the somewhat advanced in life at risk (PROSPER) (6) provides the chiefly evidence about older patients. This subject of attention enrolled participants 70 to 82 years of age, and 3239 participants (56 percent) were in the primary prevention dispose In this group, there was no statistically significant difference in the primary issue of nonfatal myocardial infarction, CHD-related death, or stroke

NCEP ATP-III (5) recognizes the uncertainty in prescribing lipid-lowering therapy in older patients with certain conditions. For primary prevention in characters at least 65 years of age, clinical long head plays an increasingly important part in decisions about LDL-lowering therapy. Framingham risk scores are les robust in older individuals. Other factors including concomitant chronic diseases, social circumstances, chronologic and functional age, and financial considerations must be taken into account when making decisions about therapy, especially about use of LDL-lowering remedys in older persons. Therefore, in women and older patients, it remains uncertain if statins are efficacious in primary prevention.

MICHAEL ALLEN, MD

in succession behalf of the Canadian Academic Detailing Collaboration

Office of Continuing Medical Education

Dalhousie University

5849 University Ave.

Halifax, Nova Scotia, Canada B3H 4H7

REFERENCES

(1) Shepherd J Cobbe SM Ford I, Isles CG Lorimer AR, MacFarlane PW et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. West of Scotland Coronary Prevention reflection Group. N Engl J M 1995;333:1301-7

(2) Downs JR Clearfield M Weis s Whitney E, Shapiro DR, Beere PA, et al. Primary prevention of acute coronary affairs with lovastatin in men and women with average cholesterol levels: comes of AFCAPS/TexCAPS. Air Force/Texas Coronary Atherosclerosis Prevention application of mind JAMA 1998;279:1615-22.

(3) separate PS, Dahlof B, Poulter NR Wedel H Beevers G Caulfield M et al, ASCOT investigators. Prevention of coronary and blow events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac consequences Trial-Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controll trial. Lancet 2003;361:1149-58

(4) Walsh JM Pignone M unsalable article treatment of hyperlipidemia in women JAMA 2004;291:2243-52

(5) Final Report of the Third Report of the National Cholesterol Education Program (NCEP) clever Panel on Detection, Evaluation, and Treatment of High children Cholesterol in Adults (Adult Treatment Panel III). Accessed online February 3 2006 at: http://www nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf.

(6) Shepherd J Blauw GJ Murphy MB Bollen EL Buckley BM Cobbe SM et al; for the thrive study group. PROspective Study of Pravastatin in the somewhat advanced in life at Risk. Pravastatin in somewhat old individuals at risk of vascular disease (PROSPER): a randomised controll trial. Lancet 2002;360:1623-30