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High cholesterol is an important risk factor contributing to the global burden of disease. A WHO report estimated that it accounts for more than one-third of all deaths worldwide, and causes 18% of cerebrovascular disease (CVD) and 56% of ischaemic heart disease.1
The evidence that lipid-lowering drugs can reduce both lipid levels and the risk of heart attacks and strokes is well established. Lipid-lowering medications include statins, fibrates, niacin and bile acid resins. The effectiveness of statins is supported by large randomised trials and meta-analyses2 3 showing that the absolute reduction in LDL-cholesterol is linearly related to a reduction in the incidence of coronary and major vascular events.2 Statins are recommended as first-line therapy, whereas fibrates, niacin and bile acid resins are generally second-line therapy, alone or in combination with statins.4 5
Despite this evidence and the availability of guidelines, lipid-lowering therapy is still underused. Although recommendations about drug treatments vary between countries, most generally recommend statin treatment in people with clinical evidence of CVD to reduce further ischaemic events. In adults who have no history of a cardiovascular event, lipid-lowering medication is recommended if there is a 20% or greater risk of developing CVD in the next 10 years.4 Recommendations by the American College of Cardiology/American Heart Association have recently broadened the indications for lipid-lowering therapy, adding to the challenge of ensuring adequate treatment coverage.5
Adherence to treatment is important for optimal effectiveness. Adherence is defined as the extent to which people take medication as prescribed. A number of factors have been linked to poor adherence, such as lack of knowledge, denial, adverse effects, impaired memory and non-acceptance of treatment. Interventions to improve adherence to medication can focus on the person (patient education), the drug regimen (simplification of regimens), the physician (decision-making aids) …
Contributors MLvD led the review team and provided oversight and statistical expertise, manuscript writing, and gave direction to the group. MDM, RU and JPS contributed to the selection of studies, data extraction, assessment of risk of bias in included studies, pooling of data, manuscript writing and data analysis. PD was part of the original author team and for this update assisted with proofreading and manuscript writing. RD assisted with management of the project, guidance of study team, study inclusion and manuscript writing. MLvD wrote the manuscript for this abbreviated version of the Cochrane review for Heart. MLvD is guarantor.
Competing interests None declared.
Patient consent This study was a meta-analysis of published data and did not involve collection of data from individual patients.
Provenance and peer review Commissioned; internally peer reviewed.