Raising HDL-cholesterol and lowering CHD risk: does intervention work?
Department of Vascular Biochemistry, Division of Cardiovascular and Medical Sciences, Macewen Building, Glasgow Royal Infirmary, North Glasgow University Hospital Division, 8 Alexandra Parade, Glasgow G31 2ER, UK
*Corresponding author. Tel: +44 141 552 0689; fax: +44 141 553 1703. E-mail address: sbrownlie{at}clinmed.gla.ac.uk
Epidemiological studies have associated low HDL-cholesterol with an increased risk of morbid coronary events. Accordingly, intervention to correct low HDL-cholesterol may be cardioprotective. A number of randomized intervention studies have addressed this hypothesis using fibrates (the Veterans Affairs HDL Intervention trial, the Helsinki Heart Study, and the Bezafibrate Infarction Prevention trial), or nicotinic acid, alone [Coronary Drug Project (CDP)] or in combination [the HDL Atherosclerosis Treatment Study (HATS) and the Stockholm Ischaemic Heart Disease study (IHD)]. These trials demonstrate conclusively that treatments to increase HDL-cholesterol deliver clinically significant improvements in prognosis. Of these trials, the largest improvement in outcomes occurred in the HATS trial, where the incidence of a combined coronary endpoint (coronary death, non-fatal myocardial infarction, confirmed stroke, or revascularization for worsening ischaemia) was reduced by 60–90% in patients receiving treatment based on nicotinic acid combined with a statin. The benefits of nicotinic acid-based treatment appear to be durable, as significant outcome benefits were visible in the group of patients initially randomized to nicotinic acid in the CDP 15 years after randomization, i.e. 9 years after the end of double-blind treatment. The combination of nicotinic acid with a statin appears to be a rational, effective, and safe strategy for minimizing cardiovascular risk in patients with dyslipidaemia.
Key Words: HDL-cholesterol • Atherosclerosis • Cardiovascular risk • Dyslipidaemia