It is no longer appropriate to describe the two opposing papers on the cholesterol debate [1, 2] as "classic snail and evangelist documents" [3]. "Evangelist" is a metaphor for one who demands public health action based on best judgment, whereas a "snail" requires more rigorous proof [3]. Two decades ago, a recommendation to lower cholesterol levels might have been justified on the basis of plausible interpretations of the available data. In the face of imperfect knowledge and incomplete agreement, physicians have a duty to act for patients' interests according to their best medical judgment. However, evangelism for cholesterol screening is less justified now than it was 20 years ago. Today's evangelism for the cholesterol idea goes far beyond the metaphorical meaning used by Dr. Davidoff [3]: It is now based less on judgment and more on faith.

Numerous large, well-designed clinical trials, described in Garber and colleagues' paper [1], have shown beyond a reasonable doubt that lowering cholesterol for primary prevention has little meaningful benefit. Before the clinical trials, the issue involved a "glass half full, glass half empty" debate. The trial results, obtained with much effort and great public expense, make it clear that the glass is, at best, 95% empty. Repeated failure to improve survival establishes a disappointingly feeble upper bound for the potential benefits of cholesterol lowering. Indeed, we cannot confidently tell the public that it is completely safe to lower cholesterol with methods now widely in use.

With the data from the primary prevention trials in hand, the old justifications for the cholesterol campaign lose their persuasiveness. The association of cholesterol levels with heart disease provided a solid rationale for undertaking the trials. In light of the trial results, however, it is no longer a valid justification for the cholesterol-lowering campaign [2].

Showing that cholesterol is present within coronary plaque raised important questions but does nothing in itself to refute the new findings or to establish the benefit of cholesterol lowering. Optimistic extrapolations from the statin trials do not invalidate the actual data [1] on primary prevention for a general population. The fervor of cholesterol theorists has paradoxically increased in response to the disappointing findings of the trials. The screening campaign is increasingly based on an evangelism divorced from reality.