Cholesterol lowering trials: advice for the British physician

In summary, there is considerable agreement as to the appropriate management of hyperlipidaemia in patients at high risk of CHD. As in all branches of medicine, there are contentious areas particularly with respect to the 'middle risk range', where a strong case can be made for further appropriate clinical trials to be performed. Several of the hitherto published guidelines for the treatment of hyperlipidaemia have been inconsistent and have overestimated the proportion of the population who would benefit from the therapeutic intervention. Nevertheless, the reality of the situation in contemporary British clinical practice is that a large proportion of high-risk patients are not adequately treated, and that the perfectly reasonable clinical aphorism of 'first do no harm' is erroneously extrapolated and used as a therapeutic nihilist's charter. As always, British clinicians will use their discretion in the treatment of individual patients, but where consensus clearly does exist, it would be an appropriate subject of clinical audit to review not only those patients who may be inappropriately receiving lipid lowering drugs but, equally if not more importantly, also to justify why large numbers of patients who would clearly benefit from such drug intervention are not currently receiving it. The cholesterol debate should no longer be the justification for therapeutic nihilism.