Dyslipidemia guidelines
=======================

* Jacques Genest

Celio Levyman mentions the massive demographic changes taking place in countries with emerging market economies, where urbanization is occurring at an unprecedented rate. In Costa Rica, urbanization caused a marked shift in dietary and exercise patterns with a concomitant increase in cardiovascular risk factors,1 and at a global level such changes have been emphasized by Yusuf and colleagues.2 We agree that the recommendations of Wald and Law3 may not be appropriate in a primary prevention setting. The risk reduction estimates calculated by Wald and Law may be overly optimistic and could distract attention from an unambiguous message promoting exercise, diet, weight reduction and smoking cessation. 

Hugh Hindle points out the dilemma caused by elevation of cholesterol in asymptomatic elderly patients. As he notes, most of their risk is attributable to age, and cholesterol reduction might not be expected to yield a marked decrease in cardiovascular disease in a primary prevention setting. This finding is echoed by the relatively small benefit observed in the PROSPER (PROspective Study of Pravastatin in the Elderly at Risk) study, in which pravastatin (40 mg/day) was given to elderly subjects.4 However, many guidelines are available for the treatment of high cholesterol, and the 1998 guidelines cited by Hindle are now somewhat out of date. The Canadian guidelines,5 which are offered in a single-page format for ease of use, are based on data from recent studies and are among the most aggressive of currently available guidelines.

**Jacques Genest** Working Group on Dyslipidemia and Coronary Artery Disease Prevention Montréal, Que.

## Footnotes

*   *Competing interests:* The author has received speaker fees from various drug companies, including those that manufacture drugs used to treat dyslipidemia and cardiovascular disease; he has also been a member of advisory boards of various drug companies.

## References

1.  1. Campos H, Mata L, Siles X, Vives M, Ordovas JM, Schaefer EJ. Prevalence of cardiovascular risk factors in rural and urban Costa Rica. Circulation 1992;85(2):648-58. 
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MTQ6ImNpcmN1bGF0aW9uYWhhIjtzOjU6InJlc2lkIjtzOjg6Ijg1LzIvNjQ4IjtzOjQ6ImF0b20iO3M6MjI6Ii9jbWFqLzE3MS8yLzExOC4zLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  2. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: part I. General considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation 2001;104(22):2746-53.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MTQ6ImNpcmN1bGF0aW9uYWhhIjtzOjU6InJlc2lkIjtzOjExOiIxMDQvMjIvMjc0NiI7czo0OiJhdG9tIjtzOjIyOiIvY21hai8xNzEvMi8xMTguMy5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

3.  3. Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ 2003;326(7404):1419-24.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjEzOiIzMjYvNzQwNC8xNDE5IjtzOjQ6ImF0b20iO3M6MjI6Ii9jbWFqLzE3MS8yLzExOC4zLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

4.  4. Shepherd J, Blauw GJ, Murphy MB, Bollen EL, Buckley BM, Cobbe SM, et al; PROSPER Study Group. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet 2002;360(9346):1623-30.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1016/S0140-6736(02)11600-X&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=12457784&link_type=MED&atom=%2Fcmaj%2F171%2F2%2F118.3.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000179393900006&link_type=ISI) 

5.  5. Genest J, Frohlich J, Fodor G, McPherson R (the Working Group on Hypercholesterolemia and Other Dyslipidemias). Recommendations for the management of dyslipidemia and the prevention of cardiovascular disease: summary of the 2003 update. CMAJ 2003;169(9):921-4.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxNjkvOS85MjEiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTcxLzIvMTE4LjMuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9)