Population benefits of cholesterol reduction: epidemiology, economics, and ethics

Cardiovascular disease mortality-rate reductions have slowed in the United States in the last decade, suggesting that additional strategies are needed to reduce rates further. Population-wide cholesterol reduction is a promising approach. Selection of a particular strategy is less an issue of efficacy, which has been proven through numerous studies, than it is an issue of epidemiology, economics, and ethics. These 3 imperatives constitute the foundation of renewed efforts to reduce the US population’s cholesterol levels. Epidemiologic imperatives include risk reduction in low-to-moderate risk individuals, who comprise approximately 30% of the population and one third of incident cases of coronary disease. Any cholesterol-lowering strategy must address the challenge of reducing the incidence of coronary disease; to do otherwise will result in an increasing prevalence of disease, with the attendant cost and disability burdens. Economic imperatives include the extension of preventive coverage to the low-to-moderate risk segment of the population, which currently is not included in any risk-reduction programs. Although cholesterol reduction with pharmacologic agents may not meet current standards for cost-effectiveness, over-the-counter (OTC) agents are under the rubric of individual, not societal, costs. Finally, current and proposed options for nonprescription cholesterol-lowering drugs raise a number of ethical issues such as beneficence, nonmaleficence, justice, and autonomy. Population-wide cholesterol reduction must be a mainstay for any strategy to reduce the burden of cardiovascular disease.