Letter: Coronary puzzle

the World Health Organisation Monica study as showing tobacco and cholesterol to be "irrelevant" as risk factors for coronary heart disease ("Doctor, doctor - can I have a fag and a chip butty now?", 15 September). He then takes the British Heart Foundation to task for continuing to believe that they are indeed important and modifiable risk factors.

Every study that has observed the health of individuals over many years has confirmed the importance of cigarette smoking, blood pressure and blood cholesterol in the development of coronary heart disease. In addition, during the last five years, several studies have clearly demonstrated that lowering blood cholesterol levels among high-risk patients reduces both death and disability from coronary heart disease.

In studies like Monica, which look at different populations through a series of snapshots over time, other factors may be at work. Jeremy Laurance raises the issue of low-grade infection as a cause of coronary heart disease. There is currently much interest in this topic but its role as a risk factor remains unproven. As he acknowledges, we believe it possible that increasing affluence in society may explain some of the decline in death from coronary disease. Whether that is due to the availability of new and expensive treatment or the ability to afford a healthier diet and more physical recreation we do not know. There is however no doubt that death from coronary artery disease is falling most rapidly in the wealthier sections of society.

We do not believe that the cause of coronary heart disease is cut and dried and have never suggested that it is completely avoidable. There is however much we can do as individuals to reduce risk and the British Heart Foundation will continue to promote this message.

Professor B L PENTECOST

Medical Director

British Heart Foundation

London W1