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Book Review |
2123 Cumming Road Augusta, GA 30904-4333 E-mail: efeldman{at}csranet.com
This excellent and useful monograph updates the effect of cholesterol lowering by drugs and diet in reducing the death rate from coronary heart disease (CHD). The authoritative volume is intended for practicing physicians involved in the primary prevention and treatment of heart disease. Six chapters detail different large clinical trials and are contributed by the investigators who designed and coordinated the trials. Angiographic data, plaque progression and stabilization, and carotid ultrasonographic outcomes are reviewed and analyzed, including a meta-analysis, in 4 other chapters. The last chapter reevaluates the effect of cholesterol lowering by statins on mortality by analyzing 12 trials.
Grundy presents a historical perspective in the opening chapter and reviews the early work (1950 on) that proposed the cholesterol hypothesis, ie, that increasing concentrations of cholesterol raise the risk of CHD. Salient points include that risk reduction is achieved after 
5 y of cholesterol-lowering treatment, that benefit in angiographic studies extends beyond changes in plaque, that more aggressive LDL lowering to <100 mg/dL (<2.59 mmol/L) reduces progression even more, and that all CHD patients should be treated to lower their cholesterol.
The trials reviewed include the Scandinavian Simvastatin Survival Study (4S), the Cholesterol and Recurrent Events Trial (CARE), the West of Scotland Coronary Prevention Study (WOSCOPS), the Program on the Surgical Control of the Hyperlipidemias (POSCH) Trial, the Air Force/Texas Coronary Atherosclerosis Prevention Study (AFCAPS/TexCAPS), and the Long-Term Intervention with Pravastatin in Ischemic Disease (LIPID) Study. Data in figures and tables that interested me include the following: 1) that mean total cholesterol and LDL-cholesterol concentrations in CHD patients in many trials, starting with the Framingham Study, are only slightly higher than those in the US population as measured in the third National Health and Nutrition Examination Survey; 2) that the WOSCOPS trial risk criteria for primary CHD prevention include smoking, diabetes, minor abnormalities in electrocardiogram results, preexisting vascular disease, hypertension, family history, and HDL cholesterol <40 mg/dL (<1 mmol/L); 3) that differences in benefit are found between women and men; and 4) that the calculated weighted linear regression between rates of cardiovascular events and the ratio of angiographic progression to regression in 6 trials with interventions including lifestyle, resins, fibrates, statins, surgical, or a combination was r = 0.92.
Other valuable information for readers includes 1) that patients with higher triacylglycerol concentrations benefited most in the 4S trial, perhaps related to associated small, dense LDL particles; 2) that data analysis can be performed to examine the cost-effectiveness of treatment; 3) that comparable risk reduction with cholesterol lowering is achieved across all tertiles of baseline LDL; 4) that there is a marked tripled risk of progression with low HDL (<35 mg/dL, or 0.91 mmol/L); 5) that plaque stabilization and improved endothelial function, rather than the morphology of coronary segments, are linked to lipid-lowering; 6) that there is a 1:1 correlation between the percentage of LDL lowering and the decrease in coronary events; and 7) that there is a need to measure LDL and HDL cholesterol as well as total cholesterol for risk assessment.
Homocysteine is discussed as a strong predictor of cardiovascular mortality, and patients with elevated lipoprotein(a) who are at high risk and should be managed aggressively. Although no large-scale diet intervention trial has been conducted, the Ornish lifestyle, the St. Thomas' Atherosclerosis Regression Study (STARS) diet treatment, and the Heidelberg diet and exercise interventions also showed risk reduction benefits.
This compact book is easy to read. The chapters are fairly equal in length, 25 pages, with generous use of clear tables and figures; are well referenced; and have little overlap or redundancy. One suggestion for the next printing or edition is to correct the typographic errors, especially in the first chapter. I recommend this book highly to students, trainees, physicians, and other health professionals interested in an objective, scientific review of the interrelations of circulating lipids and lipoproteins, atherosclerosis, cardiovascular imaging, and cardiovascular events that should aid in treatment decisions.
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