Cutting Into Cholesterol-Reply

In Reply.—  Dr Goldstein raises the difficult issue of whether the lack of overall mortality reduction in primary prevention trials implies that there are no benefits, in terms of life expectancy, from reducing cholesterol levels. He correctly points out that the only study to show a definite mortality benefit was a secondary prevention trial using niacin. Those studies that have examined the cost-effectiveness of cholesterol reduction¹ or the expected gain in life-years² have used the relationship between cholesterol level reduction and primary cardiovascular end points (myocardial infarction and coronary-related death) observed in the Coronary Primary Prevention Trial (CPPT) as quantitative validation of the cholesterol-coronary heart disease risk identified in the Framingham Heart Study, and have calculated years of life gained from the Framingham data set. We restricted our analysis to coronary heart disease-related morbidity and mortality because we could see no reasonable causal link between cholestyramine and accidental