Book Review

Lowering Cholesterol in High-Risk Individuals and Populations

N Engl J Med 1995; 333:740-741September 14, 1995

Article

Lowering Cholesterol in High-Risk Individuals and Populations
(Fundamental and Clinical Cardiology. Vol. 24.) Edited by Basil M. Rifkind. 372 pp. New York, Marcel Dekker, 1995. $125. ISBN: 0-8247-9412-5

This multiauthored textbook by well-known authorities is “intended to be of interest to primary care physicians, internal medicine practitioners, cardiologists, pediatricians, epidemiologists, public health physicians, clinical chemists, dietitians, and nurses involved in preventive care.” Therein lies one of the major problems. It is difficult to be all things to all people. The approach is more pedagogic than practical. It is entirely too detailed for some of the intended readers and probably not detailed enough for those familiar with the field. Overall, the book is well written, but there is considerable overlap among the chapters, several of which detail information provided in reports of the National Cholesterol Education Program. Several chapters review the well-known evidence of the relation between blood cholesterol and coronary heart disease. Two chapters cover nutrition exclusively, and several others contain nutritional information. As a consequence, the chapters are self-contained but repetitious and lack a thread of continuity.

The first three chapters provide an excellent source of information on available data and strategies for reducing the occurrence of coronary heart disease. Several potential problems include a controversial recommendation to delay lipid screening for those without other risk factors until they enter the medical system for another ailment and the mention of combination therapy with fibrates and reductase inhibitors without qualification. The chapter on low cholesterol is a thorough review of the topic and dispels the idea that cholesterol lowering increases the risk of death from noncardiovascular causes. Chapter 3, “Secondary Prevention of Coronary Heart Disease,” gives a thorough overview of previous secondary-prevention trials, especially in relation to meta-analyses. A section on conclusions and implications provides a helpful interpretation for those not familiar with these types of analyses. “Evolution of the Atherosclerotic Plaque” and “Emerging Opportunities for Atherosclerosis Prevention: Beyond Cholesterol-Lowering Therapy” are thought provoking and informative.

Several chapters deal with special populations. The chapter on older people presents a balanced view of the dilemma involved in treating this population. The authors review the relation between dyslipoproteinemia and changes in life expectancy but do not discuss the difficulty in using prolongation of life as a variable to evaluate efficacy in older patients. The excellent chapter on coronary heart disease in women emphasizes the benefit derived from lowering low-density lipoprotein cholesterol levels. The chapter on cholesterol levels in children is well written but generally a reaffirmation of previous recommendations.

The goal of the chapter entitled “Population Strategy” was to examine this strategy to reduce disease on the national level, but it deals mainly with dietary considerations. Although it lists many of the barriers to the success of a population strategy, it makes no mention of a major concern, the presentation of conflicting data to the public without appropriate explanations. This can lead to misconceptions about the consistency of recommendations. The chapter on the community approach contains useful hints on possible community projects and is a natural extension of the chapter on population strategy. It also discusses recommendations but from a different perspective.

“The Cholesterol-Lowering Diet” is a careful and scholarly review of the relevant data but conveys no clear message on relative or absolute efficacy. It does not specify how far the cholesterol level will be lowered in the average patient treated with dietary therapy or in different kinds of patients. No mention is made of potential modulating effects on patients' responsiveness to dietary therapy. The more practical chapter on implementing dietary change contains useful suggestions and information. The complex algorithms for dietary treatment and assessment of energy and the tables for assigning roles for physicians, registered dietitians, and other health professionals in the implementation of diets are not likely to be helpful to most readers.

The brief chapter on drug therapy does not address some basic issues, such as the dose–response relation for resins and coenzyme A reductase inhibitors and the differences in side effects, doses, and lipoprotein changes between immediate-release and delayed-release niacin preparations. The clearly written chapter on cost effectiveness is an excellent review of a difficult topic for most physicians. The section on measuring cholesterol and other lipids is helpful in the interpretation of laboratory results, but the section on compact analyzers should have discussed quality control and dealt better with apolipoproteins.

This expensive book is likely to be most useful to clinicians and investigators who do not deal routinely with lipid problems. Nonetheless, it is a compendium of many of the useful references relevant to the topic, and the reviews are comprehensive and thoughtful.

Albert Oberman, M.D.
University of Alabama at Birmingham, Birmingham, AL 35205

Robert Kreisberg, M.D.
Baptist Health System, Inc., Birmingham, AL 35213