The European Society of Cardiology
Is high-density lipoprotein the protector of the cardiovascular system?
The Heart Research Institute, Sydney, New South Wales, Australia
* Professor Philip Barter, MD, PhD, FRACP, Director, The Heart Research Institute, 145 Missenden Road, Camperdown, Sydney, NSW 2050, Australia. Tel.: +61-295503560; fax: +61-295503302
p.barter{at}hri.org.au
Abstract
Low high-density lipoprotein (HDL-C) cholesterol is a powerful predictor of risk for coronary heart disease (CHD), and raising HDL-C reduces CHD risk, with available data indicating a 1% decrease in risk with each 1% increase in HDL-C. Both epidemiological and intervention studies have shown that HDL is predictive of risk independent of low-density lipoprotein cholesterol. In treatment trials, both fibrates and statins have been shown to reduce risk in patients with low HDL-C. Statins reduce risk across all HDL-C levels from low to high, whereas fibrates appear to have benefits limited to low HDL-C in the context of the metabolic syndrome. The primary management component of increasing HDL-C is lifestyle intervention focusing on diet, exercise and smoking cessation. Drug options for raising HDL-C include niacin (+10–30%), fibrates (+5–25%) and statins (+3–12%). Niacin is poorly tolerated. Fenofibrate may pose advantages over gemfibrozil among fibrates. Findings in the large-scale Statin Therapies for Elevated Lipid Levels compared Across dose ranges to Rosuvastatin (STELLAR) trial indicate that rosuvastatin has the best HDL-C raising effect among statins. Selection of therapy requires consideration of the individual patient’s overall risk profile.
Key Words: Coronary heart disease • High-density lipoprotein cholesterol • Low-density lipoprotein • Statins • Fibrate • Niacin