Cholesterol management in high-risk patients without heart disease. When is lipid-lowering medication warranted for primary prevention?

A particularly important question for primary prevention of CHD is when to initiate cholesterol-lowering drugs in patients at risk. The two most important factors to consider are the serum LDL cholesterol level and the absolute risk, based on the presence or absence of other risk factors. The intensity of therapy can be modified according to the other risks at play. For example, diabetes mellitus is a particularly powerful risk factor for morbidity and mortality from CHD. Therefore, middle-aged or elderly diabetic patients can reasonably be treated as if they already have established CHD. Other risk factors are less dangerous, but when a patient has several such factors, intensive cholesterol-lowering therapy often is indicated. Except for patients at highest risk, a 3- to 6-month trial of nondrug therapy is warranted in an effort to achieve the target of therapy without drugs or with low doses of drugs. If patients are appropriately selected for therapy, cholesterol management for primary prevention of CHD should rival secondary prevention in reducing the burden this disorder imposes on society.