To the Editor–With regard to an article recently published in this journal, we would like to state our disagreement with the conclusion drawn. The conclusion stated that rosuvastatin dominates atorvastatin because it is more effective and less costly [1]. We disagree with this conclusion because this cost-effective analysis was performed by using just surrogate end points without clinically meaningful outcomes and did not incorporate important safety data about rosuvastatin.

It is very clear at present that when using statins the most important outcome is neither the reduction of low-density lipoprotein cholesterol (LDL-C) levels nor the increase of high-density lipoprotein cholesterol levels (both surrogate end points) but rather the decrease of hard end points, such as myocardial infarction, hospitalization for unstable angina, stroke, death form cardiovascular causes and sudden death. Therefore, it is essential to realize the limitation of surrogate end points in assessing both the efficacy and also the potential harmful effects of new medicines [2].

We do think that the efficacy of new drugs should be based on clear and reliable proof of clinically relevant outcomes (cardiovascular events avoided, deaths averted, lives saved, etc.) and the end result of performing a cost-effectiveness analysis with surrogate end points is a partial result that may confuse decision-makers and their determinations. This is particularly important if we take into account that every single statin has demonstrated benefit in terms of these clinically relevant outcomes in large randomized clinical trials, with the exception of rosuvastatin.