According to conventional wisdom it is wise to lower your cholesterol if it is too high. The main reason for this advice is the observation that people with a high cholesterol more often get a heart attack than people with a normal or a low cholesterol. The observation is correct, but it does not mean that the high cholesterol is the cause of the heart attack (see section 1). If it were, lowering of the high cholesterol by any means should prevent it, but it doesn´t (except with the new group of cholesterol-lowering drugs, the statins; see below).

More than 40 trials have been performed to test if cholesterol-lowering can prevent a heart attack. In some of the trials the number of fatal heart attacks were lowered a little, in other trials the number of fatal heart attacks increased. Overviews of the trials have shown that when all results were taken together, just as many died in the treatment groups (e.g. those whose cholesterol was lowered) as in the untreated control group (78,79). The following table gives the accumulated results. None of the differences were statistically significant. Nor were they by more sophisticated analyses.

That some overviews have shown a positive result after cholesterol-lowering is because they had ignored or excluded one or more trials with a negative outcome (79).

In a recent overview (80) the outcome was improved in a small group of trials (comprising patients at a very-high risk). However, in a much larger group of trials, namely those comprising patients at a not so high risk (but still at a high risk), mortality increased after cholesterol lowering. As it is impossible before treatment to know if a patient is at a very-high risk or only at a high risk (81) the chance is obvious greater that treatment will worsen rather than benefit the patient.

In an overview in the Feb 5 1994 issue of British Medical Journal Law and coworkers presented arguments for cholesterol lowering, either by drugs or by diet. However, according to their own analysis mortality from other causes than heart disease increased after drug treatment resulting in an unchanged total mortality, both after drugs and diet (table V, page 378). Furthermore, two large unfavourable trial branches had been excluded. (More critical comments to this analysis are found in eight letters in the April 16 issue of the journal).

The mentioned overviews included mostly diet and/or the older cholesterol-lowering drugs. But a new type of drugs, the socalled statins (for instance Zocord® and Pravachol®) have been succesful. However, their effect isn´t exerted through cholesterol-lowering (see section 6).

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