Cardiovascular disease remains the primary cause of death and medical expenditures in the United States. Despite overwhelming evidence that we can greatly improve outcomes in at-risk populations by using lipid-lowering therapy, Dr. Golomb [1] rehashes a tired and largely unsubstantiated association between cholesterol lowering and violence. She cites eight meta-analyses of cholesterol lowering that reported a higher odds ratio of violent deaths. However, none of these was a prospective trial, four of the eight did not report statistically significant findings, and most patients described in these analyses were not treated with statin drugs.

In contrast, the Scandinavian Simvastatin Survival Study [2] revealed a dramatic improvement in overall mortality in treated patients with coronary heart disease (CHD) (relative risk for death in the simvastatin group, 0.70; P < 0.001). Non-CHD mortality, including deaths from violence, did not increase. In patients with CHD but average cholesterol levels (mean level, 209 mg/dL), pravastatin therapy resulted in reduced rates of fatal and nonfatal myocardial infarction and stroke and the need for coronary bypass surgery without any significant change in mortality from noncardiovascular events or an increase in violent deaths [3]. In men with elevated cholesterol levels (mean level, 272 mg/dL) and no history of myocardial infarction, pravastatin therapy significantly reduced the incidence of myocardial infarction and death from cardiovascular causes without adversely affecting the risk for death from noncardiovascular causes or violence [4]. These three prospective, controlled studies alone randomly assigned more than 15 000 persons. This design was not used by the various smaller studies subsequently lumped into the meta-analyses cited by Dr. Golomb.

Dr. Golomb may be correct that more work needs to be done to evaluate the effects of cholesterol lowering on violence in hyperlipidemic primary prevention populations. Unfortunately, she has inexplicably ignored the greater tragedy. Despite over-whelming evidence of the benefits of cardiovascular risk factor modification, 85% of patients with CHD and 57% of those with more than two risk factors do not receive treatment to achieve the ideal low-density lipoprotein cholesterol levels defined by the National Cholesterol Education Panel [5].