Introduction
University of Münster
Münster
Germany
INSERM
Paris
France
Glasgow Royal Infirmary
Glasgow
UK
Recent decades have seen dramatic improvements in our ability to improve patient outcomes by reducing the risk of cardiovascular events. These improvements have arisen both from the major advances in our understanding of the biochemical and cellular basis of atherosclerosis and coronary artery disease and through the availability of new treatments directed at specific cardiovascular risk factors. The introduction of the statins, in particular, has transformed the way in which we care for our dyslipidaemic patients. These agents have proved effective at reducing cardiovascular risk irrespective of the patients' age, comorbidities, or severity of hyperlipidaemia, and will remain at the core of our clinical practice for the foreseeable future.
Lowering LDL-cholesterol, the principal action of the statins, addresses only one aspect of cardiovascular risk arising from dyslipidaemia. Accordingly, the latest evidence from randomized clinical trials suggests the presence of an upper limit to the benefit that can be achieved from these agents. Since the Framingham Study in the 1970s, we have known that low HDL-cholesterol is also strongly and independently associated with elevated cardiovascular risk. Moreover, low HDL-cholesterol is commonly found among the dyslipidaemic population, especially in populations characterized by insulin resistance, such as patients with type 2 diabetes or the metabolic syndrome. Simultaneous interventions to reduce LDL-cholesterol while raising HDL-cholesterol present a rational and increasingly evidence-based strategy for achieving the next leap forward in cardiovascular risk management.
A world-class faculty came together to discuss the current and future role of HDL-raising in cardiovascular care at the International Merck Symposium on HDL raising: Beyond LDL-C Reduction: New Paradigms in the Reduction of Cardiovascular Risk, held in Rome, 1–2 October, 2004 (sponsored by an unrestricted educational grant from Merck KGaA). This event gave rise to a series of comprehensive and thought-provoking state-of-the-art reviews. These include articles on the mechanisms of atherosclerosis, cardiovascular risk assessment based on major epidemiological cohort studies, the current status and future prospects for interventions aimed at LDL-lowering, and the evidence base that demonstrates the potential of combined LDL-lowering and HDL-raising, for example, with a statin combined with nicotinic acid, to prevent cardiovascular events by inhibiting the progression of atherosclerosis.
The speakers also addressed practical issues in the delivery of cardiovascular care. Nicotinic acid (niacin) is highly effective in raising HDL-cholesterol, although providing useful improvements in other lipid parameters, and has been available for many years. However, tolerability issues, especially a high incidence of flushing, have hindered its use. A new prolonged-release formulation of nicotinic acid, Niaspan®, provides the efficacy of standard nicotinic acid on HDL-cholesterol raising, with a significantly reduced incidence of flushing per patient. Clinical experience to date suggests that this prolonged-release formulation shares the HDL-cholesterol raising and anti-atherogenic effects of the older immediate-release nicotinic acid formulation.
These reviews have been brought together in this supplement. We hope you find them interesting and useful in your clinical practice.
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