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Starting statins for primary prevention of cardiovascular disease
  1. Hugh Tunstall-Pedoe
  1. Correspondence to Professor Hugh Tunstall-Pedoe, Cardiovascular Epidemiology Unit, Ninewells Hospital and Medical School, University of Dundee, Dundee DD1 9SY, UK; h.tunstallpedoe{at}dundee.ac.uk

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Fifty years ago

Despite exceptional mortality rates half a century ago, anyone in Britain asking a doctor at that time how to avoid having a coronary heart attack, or wanting their cholesterol tested, risked being labelled a hypochondriac. Cholesterol was considered an American fad. Unlike in America, medical treatment here was free—no need to worry therefore, the National Health Service would look after you. Prevention was the province of quacks and charlatans, outside the remit of orthodox medicine, the exception being fringe doctors (often regarded as failed clinicians) in public health, along with occupational physicians, obstetricians and some enthusiastic general practitioners. Consultants in hospitals were there to practise diagnosis and treatment, and that included cardiologists. Many were critical of prevention. It appeared simultaneously to be both threatening and unscientific.

Things have changed

In the 21st century things are different. Evidence based medicine challenged prejudice. Framingham and other cohort studies had introduced the concept of risk factors,1 while Stamler had pioneered preventive cardiology in the 1960s.2 Britain followed-up its 1940s invention of randomised controlled trials with its cardiologists supporting really large multicentre trials in the 1980s and 1990s,3 easing their way into preventive thinking through secondary prevention, and increased numeracy on risk. Medical advice is now no longer exclusively channelled through a personal physician: the media and the internet are awash with it. Government wants to save money by prevention. ‘Big Pharma’ have produced ever more effective drugs, and sponsored much postgraduate medical education. Guidelines and box ticking replace a large part of what was often idiosyncratic clinical judgement. Computerised patient databases provide potential for auditing clinical behaviour, implementation of guidelines, and their outcomes, both in hospitals and in the general population. We now claim to know what doctors and their teams ought to be doing, can tell them what to do (with financial …

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