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are available for the treatment of high cholesterol, and the 1998 guidelines cited by Hindle are now somewhat out of date.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
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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.