HDL cholesterol Primary Prevention High Risk + 7%* Low Risk + 1% Secondary Prevention High Risk +10%* Low Risk + 4%*

Triglycerides Primary Prevention High Risk - 11%* Low Risk - 12%* Secondary Prevention High Risk - 27%* Low Risk - 15%*

Total cholesterol/HDL Primary Prevention High Risk –15%* Low Risk - 5% Secondary Prevention High Risk – 28%* Low Risk - 8%*

Non HDL cholesterol Primary Prevention High Risk -8% Low Risk - 5% Secondary Prevention High Risk – 19%* Low Risk - 5%

* Indicates significant finding

These results after eighteen sessions of exercise over six week’s show a very significant reduction in risk of a cardiac event or second cardiac event.

However, recently newer risk factors have come into contention and the more traditional, whilst still of importance are less relevant.

Many of the older studies excluded a significant number of patients who as they did not have Total cholesterol or LDL-cholesterol abnormalities were excluded by the design of the studies.

These particularly relate to those with low HDL (Less than 1mmol/L) and moderately high triglycerides (Greater then 2mmol/L) and estimates as high as 60% of patients with significant risk factors for coronary artery disease are claimed to have been excluded by inclusion criteria.

Furthermore, whilst in the tightly controlled clinical trial situation patients are cajoled into attending for follow up and clinical investigators plagued by the Clinical Study Nurse to ensure that all records are completed – where at each visit tablet counts are made to ensure patient compliance – pristine results are ensured.

In the clinical practice arena a very different scenario is taking place. Patients who fail to re-attend for an appointment may be black listed and excluded. Where reliance is placed on the patient’s honesty to ensure that all medication is taken appropriately. Where the physician has no idea whether or not the patient has even had the prescription dispensed by a chemist.

In this scenario we find that, in the case of lipid lowering therapy, over 50% of the patients in all countries around the world have not reached their target levels for cholesterol or LDL lowering.

Even when the target may be a modest reduction (eg to attain a cholesterol level Less then 5mmol/L) over 50% of patients cannot make it for whatever reason be it non compliance, too low a dose, drug interaction, non reported side effects or ineffectiveness.

In this situation we find the “experts” or a select committee of effete professors and academics, divorced from the real world of medicine, advocating making the bar even higher (paradoxically by lowering the target level of cholesterol or LDL cholesterol).

These recommendations made simply on the results of tightly controlled pharmaceutically supported multicentre clinical trials; which have no basis in reality.

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