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Most patients who should be on lipid-lowering therapy are not receiving it, and most patients who are receiving it are not reaching their appropriate low-density lipoprotein (LDL) goals. This is in part because physicians and patients fear side effects of statins and other lipid-lowering agents. Ezetimibe (Zetia), a new lipid-lowering drug, may help physicians close this "treatment gap" in more patients, especially in combination with a statin. s KEY POINTS Ezetimibe works by inhibiting cholesterol absorption. It has a favorable side-effect profile; in particular, it does not cause hepatotoxicity or myositis, which, although uncommon, are concerns with statin therapy. Ezetimibe lowers LDL levels by about 18% when used as monotherapy and by an additional 25% when added to statin therapy. The most practical use of ezetimibe will be in combination with ongoing statin therapy in patients who have not reached their LDL goals. Ezetimibe monotherapy may be used when the patient cannot tolerate statin therapy or does not wish to use a statin. Goal LDL levels are less than 100 mg/dL for patients at high risk, less than 130 for patients at moderate risk, and less than 160 for patients at low risk.

The frequency of futile interventions appears to be low unless one is willing to accept a definition that includes patients who could survive for many months. If confirmed in other settings, this suggests that concepts of futility will not play a major role in costs containment.