Editor—Campbell et al surveyed the true rates of treatment with various forms of secondary prophylaxis in patients with coronary heart disease, at least in those general practices that participated.1 The authors do not consider the utilitarian argument that it is best to do the greatest good for the greatest number. The figure shows the number of lives saved per £100 000 spent on drugs for secondary prevention, based on the approximate number of patient years of treatment needed to save one life. If “all bad things” are considered2 then aspirin (after the first five weeks)3 and simvastatin4 will both prevent about one bad thing for every 30-40 years of patient use, but £100 000 of aspirin (half a 300 mg tablet a day) will prevent about 1300 events, while £100 000 of simvastatin (20 mg a day) will prevent only eight.
I do not argue that we should abandon secondary prevention with lipid lowering agents, but we should concentrate on doing the easy and most cost effective things well. By these criteria, aspirin, then β blocking drugs and angiotensin converting enzyme inhibitors, in suitable cases are orders of magnitude more important than statins.
References
- 1.Campbell NC, Thain J, Deans HG, Ritchie LD, Rawles JM, Squair JL. Secondary prevention in coronary heart disease: baseline survey of provision in general practice. BMJ. 1998;316:1430–1434. doi: 10.1136/bmj.316.7142.1430. . (9 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Moore A, McQuay H, Muir Gray JA. Statins. Bandolier. 1998;47:2–4. [Google Scholar]
- 3.Antiplatelet Trialists’ Collaboration. Collaborative overview of randomised trials of antiplatelet therapy. I. Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ. 1994;308:81–106. [PMC free article] [PubMed] [Google Scholar]
- 4.Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian simvastatin survival study (4S) Lancet. 1994;344:1383–1389. [PubMed] [Google Scholar]