The guidelines on cholesterol screening published by the American College of Physicians [1] are disturbing. They represent one step forward and two steps backward in achieving the goal of preventing cardiovascular disease. Furthermore, the College's approach is discordant with its mission: to establish the highest clinical standards, to be foremost in comprehensive education, to advocate responsible positions, and to serve the professional needs of its members.

Cardiovascular disease is still the most common cause of both illness and death in the United States. Although there are many risk factors for this disease, lipid abnormalities are clearly both important and modifiable. Suggesting that patients not be screened for high cholesterol levels until the age of 35 years is sticking one's head in the sand and avoiding the problem. Furthermore, it is insulting to suggest that physicians would not know what to do with information on cholesterol levels if they had it. The implication is that patients would receive medications inappropriately. The National Cholesterol Education Program has published clear and conservative guidelines on when to prescribe medicine for low-risk patients.

The idea that one can wait until coronary artery disease manifests itself shows little understanding of the pathophysiology and natural history of this disease. The real problem is not the individual person who has a family history of coronary disease. These cases are often dramatic, but they represent few of our patients. The problem lies with those persons who have "modest" hyperlipidemia and could be treated with diet and exercise. We need to realize that an "average" cholesterol level is not necessarily a desirable cholesterol level.

The suggestion that we do not need to measure high-density lipoprotein cholesterol levels is another return to the Dark Ages. Data from the West of Scotland Study [2] and the Scandinavian Simvastatin Survival Study [3] clearly show that if the appropriate persons are treated, the benefits are substantial. The notion that diet and exercise don't work is based on only a few studies. In many of my patients, they do work!

Education, the College's forte, is the key. I want to know which of my patients are at increased risk. If their lipid levels are normal, I won't repeat the tests annually, but I do repeat them every 5 to 7 years. If they have modest elevations of low-density lipoprotein levels and otherwise have low risk, I prescribe diet and exercise. If their high-density lipoprotein levels are very high or very low, I take that into account. Advocating ignorance is a disservice to the College's members.