After 4S, CARE and LIPID--is evidence-based medicine being practised?

Between 1994 and 1997, three major trials - 4S, CARE and LIPID - showed that simvastatin and pravastatin reduced the risk of a recurrent coronary event in patients with established coronary heart disease (CHD) [Scandinavian Simvastatin Survival Study (4S) Group. Lancet 1994;344:1383-89; Sacks FM et al. New Engl. J. Med. 1996;335: 1001-9; Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. New Engl. J. Med. 1998;339:1349-57]. The results of CARE and LIPID, with pravastatin, also showed that the benefits of improved survival extended to the majority of patients with CHD whose cholesterol levels were in the 'normal' range. Despite this compelling evidence, recent CHD prevention surveys between 1994 and 1998 have unveiled a wide therapeutic gap between scientific evidence and practice in the secondary prevention of CHD. These recent surveys revealed a high prevalence of hypercholesterolaemia in patients discharged from hospital and after 6 months following a coronary event, but low levels of statin prescribing in these patients. Of the minority of patients prescribed a statin by a consultant on discharge from hospital, nearly all were still receiving this treatment in primary care 6 months later. These findings therefore clearly highlight the need for an integrated approach involving hospital specialists, primary-care physicians and the patient, to overcome the wide treatment gap in lowering even 'normal' cholesterol levels in high-risk patients in line with evidence-based medicine.