PubMed · 9117136
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B Lewis. 1996. Trials, basic research and the clinician.. https://doi.org/10.1097/00041433-199612000-00001
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Cardiovascular disease, including coronary heart disease, is the leading cause of death both in men and in women in the United States. The purpose of this review is to describe the effectiveness of lipid-lowering therapy in reducing cardiovascular morbidity and mortality, which has recently been extended to patients with mild to moderate hypercholesterolemia, and the cost of providing therapy, which would be prohibitive if all persons with hypercholesterolemia received treatment. Cost-effectiveness analysis provides a rational means of allocating limited health care resources by allowing the comparison of the costs of lipid-lowering therapy, in particular, therapy with beta-hydroxy-beta-methylglutaryl-CoA (coenzyme A) reductase inhibitors (statins), with the costs of atherosclerosis that could be prevented by lowering cholesterol. To extend the benefits of treatment to the large number of persons not receiving therapy, we need to implement more cost-effective treatment by improving risk assessment, increasing treatment effectiveness, and reducing the cost of therapy.
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Coronary arteriography has played a central role in improving our understanding of the mechanisms of unstable coronary syndromes and the benefits of cholesterol lowering. However, coronary arteriography as currently used is outmoded and inadequate for new clinical algorithms based on vigorous lipid and other risk factor control as alternatives to invasive procedures for the primary treatment of coronary artery disease. What is needed is a way of viewing or analyzing noninvasive myocardial perfusion images and coronary arteriograms so as to identify and quantify the extent or severity of diffuse coronary atherosclerosis. Determining the relative contribution of diffuse and segmental narrowing by definitive myocardial perfusion imaging or coronary arteriography would provide the optimal basis for determining the need for revascularization procedures. In the absence of significant segmental stenoses, mild or diffuse disease identified by coronary arteriography would also provide a definitive diagnosis as the basis for lifelong cholesterol-lowering drugs and risk factor modification, even for patients with normal cholesterol levels. Thus, it is important to consider several new concepts for analyzing coronary arteriograms. More physiologically accurate invasive and noninvasive technology allows improved diagnosis and management of coronary atherosclerosis as new paradigms in cardiovascular medicine.