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American College of Physicians Guidelines on Cholesterol Screening

TO THE EDITOR: Opinions on a controversial subject are always appreciated, and so I read with interest the articles and guidelines on cholesterol screening in the 1 March 1996 issue [1, 2]. However, one area that seems no clearer than before is cholesterol screening and treatment in the elderly patient with established heart disease. Many older patients who have had one or more heart attacks and have high cholesterol levels are not receiving treatment, and they may not even be aware that their cholesterol levels are elevated. In my experience, this is not a rare or hypothetical situation. The guidelines [1] are not clear on this point. Although it is advised that all patients with known coronary heart disease should have lipid analysis, I also noted that screening is not recommended for men and women 75 years of age and older. Perhaps the latter admonition refers to screening for primary prevention. Indeed, the accompanying article by Garber and colleagues [2] states, Among persons in their late 70s and older mortality from coronary heart disease is not associated with elevated cholesterol levels Presumably, then, cholesterol levels in a 75-year-old person who has recently had a heart attack need not be addressed. Or should they? Perhaps it depends on the age at which the first heart attack occurred. In any case, it seems that the role of cholesterol screening and treatment in the elderly for the purpose of secondary prevention of heart disease requires further clarification.