To the Editor: In their recent article, Chen and colleagues argued for an increase in the number of Australians being treated with lipid-lowering drugs.1 It would appear pertinent to question the economic and therapeutic value of such an increase.

The daily number of doses of statins in Australia increased by 1218% over the decade to 2005.2 Australia has considerably greater use of serum lipid-lowering agents than other Organisation for Economic Co-operation and Development countries, with annual costs in 2004 of $1.61 billion.2 Four years later, following the introduction of rosuvastatin and recent media reports regarding reductions in heart attacks and strokes, this figure must have escalated.

Of necessity, the recommendation for the use of lipid-lowering therapy is largely based on extrapolation from tightly controlled clinical trials to clinical practice. This postulate has been questioned by a number of authorities, essentially due to eligibility requirements of trials excluding 40% of men and 80% of women,3 or, more importantly, because of failure to reach target levels, ranging in the world literature from 21% to 73% (references available from the author). This failure may be due to inadequate dosing or poor compliance, with non-compliance noted to be in the order of 35% at 2 years.2

In a submission to the Australian Government’s inquiry into health funding, I posed the hypothesis that if patients were required to undertake appropriate lifestyle changes before initiation of pharmaceutical intervention, annual savings of $130 million could be anticipated.4 Such an activity would also show benefits in reducing hypertension and obesity and improving glucose control in diabetic patients.

Low high-density lipoprotein (HDL) levels and moderate elevation of triglycerides (to an extent that the triglyceride–HDL ratio is greater than 2) are associated with a preponderance of type B low-density lipoprotein (LDL) particles, which are known to be highly atherogenic. High-intensity interval training over a 6-week period increases the HDL levels in patients with initial levels < 1 mmol/L and reduces triglyceride levels, to the extent that the triglyceride–HDL ratio is significantly reduced to less than 2.5 Frequent requests to pharmaceutical companies for data regarding the effect of their preparations on elevating HDL levels in patients with levels < 1 mmol/L have been fruitless.

In Australia, the incidence of coronary heart disease events decreased from 1994 to 2005, by 32% for men and 34% for women.6 Similar trends were observed for deaths from coronary heart disease and stroke.6 Year-by-year analysis of these trends fails to demonstrate any particular response in any one year. During the period 1997–2005, the increase in defined daily doses of statins rose from 20 per 1000 population per day in 1997 to nearly 180 per 1000 per day in 2005.2 One might have thought that this increase in statin therapy would have resulted in a far greater reduction in the incidence of cardiovascular disease and deaths than previously. However, this was not so — the trend continued unchanged in the “post-statin era” and of similar magnitude to the “pre-statin era”.

In the words of the late Professor Julius Sumner Miller, “Why is it so?”