Cholesterol levels and cholesterol lowering in idiopathic dilated cardiomyopathy

We read with great interest the recent article of Dr Christ et al.1 about the prognostic significance of serum cholesterol levels in patients with idiopathic dilated cardiomyopathy (IDC). It was found that decreased cholesterol levels do not independently predict adverse prognosis in patients with IDC and that low cholesterol levels are dependent on the severity of the disease (i.e. higher NYHA class, higher left ventricular end-diastolic diameter, and lower left ventricular ejection fraction). In contrast, the authors present an intriguing curve showing that, retrospectively, the prognosis (survival or transplant free survival) was significantly better for the few patients (∼15%) who received statins at any time during follow-up. As stated in the discussion, beneficial effects of statins in heart failure patients indeed appear promising in some preliminary results, even in patients without coronary artery disease.2 However, the particular analysis and results of Dr Christ may, in our opinion, be related to the fact that the patients who received statins were likely to be those with the highest cholesterol levels, i.e. those with the lower severity of the disease as suggested by the authors themselves. Therefore, it is really not sure that the better prognosis was related to the treatment with statins or to the lipid lowering. Prospective randomized intervention trials are thus particularly needed in the field.