A 23-year follow-up study of 10 059 40-to 65-year-old participants In the Israeli Ischemlc Heart Disease Study found that of 3473 deaths (34.5%), In 1098 (10.9%) coronary heart disease (CHD) was the underlying cause. Total serum cholesterol (TC) was measured in 9902 Individuals. During the study, CHD mortality was elevated primarily In Individuals in qulntiles 4 and 5 (TC levels 2217 mg/dl). Although CHD mortality Increased marginally with Increasing TC at levels below 217 mg/dl, this was

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... ly explained by age and other correlated risk factors In a multlvarlate adjustment of the survival curves. The "net" 23-year survival in terms of CHD was 87% in qulntlle 5 (TC>241) versus 93% In qulntile 1 (TC<176 mg/dl). CHD mortality was Inversely related to the percent of cholesterol In high density llpoproteln (PHDL). All-cause mortality Increased only when TC was above 240 mg/dl and In the subjects with PHDL levels in the lowest 20%. Lfpids appeared to be somewhat less effective In predicting subsequent CHD mortality than did hypertension and smoking and were clearly secondary In assessing risk of all-cause death. The results raise the question whether Intensive treatment for hypercholesterolemla is Indicated for men at "borderline" levels. We conclude that the association between serum cholesterol and long-term mortality partly reflects the role that levels of co-existing CHD risk factors play In prognosis. At the "borderline-high" cholesterol range, where preventive studies of clinically manifested end points have not been conducted and survival Is only marginally Jeopardized, the Identification and management of nonllpld CHD factors may constitute a primary preventive approach among men In populations with temporal patterns and risk factor-mortality associations similar to the ones In our cohort (Arteriosclerosis 10:512-519,