Borderline hypercholesterolaemia: when to introduce drugs.

'Please do not write any more articles about cholesterol and coronary disease and the diet and drugs which are supposed to influence them. The facts about coronary disease are these: the less atheromatous your ancestors, the harder your water, and the more habitual exercise you take, the less likely you are to be troubled by it. Do stop bothering about whether your fats are saturated or unsaturated, help yourselves liberally to butter and stop propagating these erroneous legends." This remains too frequently the view of medical practitioners in Britain. Sadly it must be one ofthe few statements of Richard Asher which does not remain as penetratingly accurate today as it was when first made: prescience had on this rare occasion deserted him. We still, of course, believe that susceptibility to coronary atheroma is in some individuals inherited, but this does not mean that their risk is immutable. Evidence that coronary disease morbidity and mortality can be decreased by therapy aimed at lowering serum cholesterol, is now strong. Indeed our patients are likely to benefit more from this than from many other medical practices, which are accepted without question.2'0 The debate concerning the 'cholesterol hypothesis' has now moved on to consider how cholesterol or some factor closely related to its metabolism provokes atherogenesis and to determine the particular levels of cholesterol at which therapeutic intervention would be expected to produce benefit." It is this latter issue which is the subject of this article. In some patients with hypercholesterolaemia (perhaps the minority) the decision to prescribe lipidlowering drug therapy, when diet has not produced a satisfactory decrease in the serum cholesterol, is easy. In others, however, it may involve a difficult clinical judgement. Indeed the majority of patients with hypercholesterolaemia must be regarded as borderline when drug therapy is to be considered. It is our purpose to provide a background of ideas, which will assist in making that decision. The origins and fate of the different lipoproteins which transport cholesterol are diverse, and it is naive in the extreme to believe that any single numerical value for the serum cholesterol can stimulate a therapeutic reflex response without the proper diagnostic assessment of each individual patient. Supposing we limited ourselves to but a single therapeutic approach to hyponatraemia: what disasters would follow! Some knowledge of lipoprotein metabolism is essential to the clinician contemplating the mangement of hypercholesterolaemia.