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CHOLESTEROL SCREENING IN YOUNG ADULTS SHOULD BE LIMITED

This article was originally published in The Gray Sheet

Executive Summary

CHOLESTEROL SCREENING IN YOUNG ADULTS SHOULD BE LIMITED to individuals at high short-term risk of death from coronary heart disease, Stephen Hulley, MD, University of California, San Francisco, et al. conclude in a study published in the March 17 Journal of the American Medical Association. "It is reasonable to measure blood cholesterol levels in those few young adults who have known coronary disease, or several other CHD [coronary heart disease] risk factors, or a first-degree relative with familial hypercholesterolemia," the researchers assert. The retrospective study was designed to assess the National Cholesterol Education Program's recommendation that adults 20 years of age and older have their blood cholesterol levels determined. Hulley et al. base their conclusions on "the fact that cost-effectiveness and benefit-to-harm ratios are strongly influenced by the level of risk in the target population." The researchers maintain that "the policy of screening and treating high blood cholesterol levels in young adults is neither cost-effective, nor does it satisfy ethical standards requiring strong evidence that preventive interventions do more good than harm." The authors assert that for low-risk individuals, defined as "healthy people with high blood cholesterol levels as their only risk factor," the low incidence of CHD mortality does not justify the expense of treatment. The researchers estimate that the cost of treating women between the ages of 25 and 34 or men between 25 and 34 with the cholesterol-lowering drug lovastin is $1-to-$10 mil. per year of prolonged life. Cost estimates for other lipid interventions such as cholestyramine were similar. Alternatives to drug treatments such as the step I fat-controlled diet, although less expensive than drug treatments, produce a sustained decrease in blood cholesterol level of less than 4%. More intensive diets, which produced larger reductions in cholesterol levels, cost more "for adequate supervision and are less acceptable to many patients," Hulley et al. argue. The study also found that for patients at a low risk for CHD, cholesterol intervention may "cause more harm than benefit" because there "is a greater chance that adverse effects could predominate. Hulley et al. maintain that the expected decrease in CHD deaths in low-risk patients is offset by statistically significant increases in deaths from other causes. The authors cite meta-analyses of primary prevention single intervention trials that found that "men assigned to cholesterol-lowering interventions had 15% fewer CHD deaths," but 43% more cancer deaths, 76% more injury deaths and 7% more deaths overall. The "most straightforward explanation" for the excess deaths is "the possibility that one or more of the cholesterol-lowering interventions cause noncardiovascular deaths," the authors state. To support the idea that screening should be postponed, the researchers argue that "cholesterol intervention prevents CHD even when treatment is not begun until middle age." Hulley et al. assert that age 35 in men and 45 in women should be considered early to begin screening, as the ages represent a decade before each group's CHD death rate reaches one in 1,000. Hulley et al. conclude that "for the great majority of young adults...a policy of not screening and treating rests on firm ethical grounds." The report cautions that a "scientific basis" for confidence that the harm does not outweigh the benefit must be established before promoting a widespread screening and intervention program. In an editorial in the same journal issue, David Naylor, MD, University of Toronto, supports Hulley et al.'s criticism of the NCEP guidelines for young adults. He asserts that an "elevated total cholesterol or low density lipoprotein level is a mediocre marker for short-term and even long-term risk of coronary events," noting the absence of a "discrete point" beyond which most people develop CHD. Naylor also points out that adherence to NCEP recommendations for screening "will run to billions of dollars, at a time when America faces health care costs exceeding 14% of gross national product and issues of coverage for tens of millions of citizens with no health insurance."

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