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Letter to the editor of Lancet submitted on December 1, 2007 by Uffe Ravnskov. Read also the editor´s answer below and Uffe Ravnskovs comments.

Blood cholesterol and vascular mortality

The authors of the Prospective Studies Collaboration (PSC) were surprised because cholesterol was associated with mortality from ischemic heart disease (IHD) in all ages, but inversely associated with stroke mortality (Dec 1). That future research may explain these findings as anticipated is unlikely; it may rather show that cholesterol is unimportant, even for IHD, because there are more contradictory findings than those presented in the PSC study.
     According to the PSC data high cholesterol was a risk factor for IHD mortality in women, although much weaker than for men. The authors have disregarded a review that included 82,237 women according to which cholesterol was not associated with IHD mortality between age 50-64 and inversely associated after age 64.1 Furthermore, many recent studies, most of which were not included, have found that high total and/or LDL cholesterol is not a risk factor in old people; in fact, some of them found an inverse association.2 These and the PSC findings together are indeed challenging considering that at least in Sweden more than 90 % of all cardiovascular mortality occur in people above age 65. 
     That high cholesterol should be the initiating factor in cardiovascular disease is also questioned by the lack of an association between LDL cholesterol and endothelial dysfunction,3 and by the fact that no post mortem study of unselected individuals has found an association between total or LDL-cholesterol and degree of atherosclerosis.4 Obviously, possible benefits from statin treatment must be due to their pleiotropic effects, not to cholesterol lowering.5   
Uffe Ravnskov

  1. Ulmer H, Kelleher C, Diem G, Concin H. Why Eve is not Adam: prospective follow-up in 149650 women and men of cholesterol and other risk factors related to cardiovascular and all-cause mortality. J Womens Health 2004; 13: 41-53.
  2. Ravnskov U. High cholesterol may protect against infections and atherosclerosis. QJM 2003; 96: 927-34.
  3. Reis SE, Holubkov R, Conrad Smith AJ, et al. Coronary microvascular dysfunction is highly prevalent in women with chest pain in the absence of coronary artery disease: results from the NHLBI WISE study. Am Heart J 2001; 141: 735-41.
  4. Ravnskov U. Is atherosclerosis caused by high cholesterol? QJM 2002; 95: 397-403.
  5. Ravnskov U. Implications of 4S evidence on baseline lipid levels. Lancet 1995; 346: 181.

 Here is the answer from the editor (my comments in bold)

Dear Dr Ravnskov,
Thank you for submitting your letter. After in-house review, I'm afraid we have decided not to accept it for publication. We regret that we are unable to write a personal note for every letter we turn down, but the following common reasons for rejection may help you with future submissions: lateness (ie, more than 2 weeks after publication of the article on which you are commenting) (the letter was sent within 2 weeks), inclusion of original research (the section is not peer reviewed, so we cannot publish such work here) (no original work was included in the letter), submission of case reports (we have a separate section for these)(it is not a case report), reiteration of points made by another correspondent (no other correspondent has responded, and inappropriate length (limits are 250 words and 5 references) (the letter has 248 words and 5 references). If none of these apply to your letter, please be assured that we have nevertheless considered it carefully and probably had to refuse it because we have simply received too much good material (No letters commenting Armitage´s review have been published).

Zoë Mullan
Senior Editor

Other unpublished contributions by members of THINCS

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