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February 3, 1999

Coronary Events With Lipid-Lowering Therapy: The AFCAPS/TexCAPS Trial

Author Affiliations

Copyright 1999 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.1999

JAMA. 1999;281(5):414-419. doi:10-1001/pubs.JAMA-ISSN-0098-7484-281-5-jbk0203

To the Editor: The AFCAPS/TexCAPS trial explores whether statin treatment should be extended to subjects without evidence of cardiovascular disease and with average total cholesterol and LDL-C levels but less than average high-density lipoprotein cholesterol (HDL-C) levels.1 AFCAPS/TexCAPs shows substantially lower benefits than previous trials in higher-risk subjects, although, unfortunately, results are presented in a noncomparable format. For 1 patient to avoid a primary end point (fatal or nonfatal MI, unstable angina, or sudden cardiac death), 244 patients have to be treated per year (NNT per year). Are the benefits achieved clinically important or a defensible use of resources? Although statins are generally well tolerated, there must be concern about medicalizing so many "healthy" subjects for such rare benefits. Furthermore, benefits of treatment appear concentrated in those with the greatest level of risk. If the authors had shown the 17% of patients who met existing National Cholesterol Education Panel (NCEP) guidance in 1 stratum and the 83% who did not in the other, would the benefits in the majority of patients have looked even less impressive? By excluding 12.4% of patients who smoked, the NNT per year increases to more than 300.

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