Guest editorial
1 Istanbul University Cerrahpasa Medical School, Istanbul, Turkey
2 Ullevål University Hospital, Oslo, Norway
3 Glasgow Royal Infirmary, Glasgow, UK
The rate of advance of cardiovascular clinical research in recent years has been astounding. A decade ago, the Scandinavian Simvastatin Survival Study and the West of Scotland Coronary Prevention Study had recently reported. These trials and the other landmark studies that followed ushered in the statin era, having demonstrated beyond doubt the benefits of intervention with a statin in populations at high risk of cardiovascular events, and dispelled for good the doubts and uncertainties over the safety of lipid lowering raised by the earlier evaluations of bile acid sequestrants.
Clinical evaluations of statins continue, mainly with the aim of controlling LDL-cholesterol to ever-lower levels to pursue additional benefits beyond the 20–40% cardiovascular risk reductions observed routinely with these agents. Increasingly, however, experts in the field are also looking to a different, but complementary approach to improving cardiovascular care by addressing forms of dyslipidaemia other than elevated LDL-cholesterol. A world-class faculty joined us, including many of the leading investigators from interventional and observational cardiovascular studies, to survey the current status and future directions of cardiovascular research at the ‘Second International Merck Symposium on HDL-C Raising’, held in Barcelona, Spain, 14–15 October 2005. This major symposium, entitled ‘Bridging the gap in cardiovascular risk reduction: a call to action’, covered all aspects of cardiovascular care. The expert presentations from the meeting addressed the early pathophysiology of atherogenesis, the development of the mature atherosclerotic plaque, and the critical properties of the unstable plaque that increase its chance of rupturing and precipitating a morbid cardiovascular event. Increasing rates of obesity, insulin resistance, and diabetes worldwide highlight the importance of an atherogenic triad of low HDL-cholesterol, hypertriglyceridaemia and small, dense LDL in elevating cardiovascular risk independently of overall levels of LDL-cholesterol. The nature of this triad, its effects on prognosis, and its high prevalence among the population of patients under treatment for dyslipidaemia were explored in depth.
Nicotinic acid (niacin) is currently the most effective means available for increasing HDL-cholesterol, and the latest data relating to the mechanism and effectiveness of this agent were discussed. The Coronary Drug Project demonstrated improved cardiovascular outcomes following intervention with nicotinic acid monotherapy in the mid-1970s, and the HDL Atherosclerosis Treatment Study confirmed and extended these findings in patients receiving nicotinic acid and a statin in 2001. Recent observational and intervention studies have defined the benefits in terms of reduced rates of atherosclerosis and improved cardiovascular outcomes from the simultaneous correction of hyperlipidaemia and low HDL-cholesterol. The introduction of Niaspan®, a once-daily nicotinic acid formulation with improved tolerability compared with the immediate-release version, has facilitated the use of nicotinic acid to correct low HDL-cholesterol. Within the past year, major new evidence of the antiatherogenic benefit of combining Niaspan® with a statin has emerged.
Our faculty has captured the main themes from their presentations in a series of state-of-the-art reviews. Together, these summarize the current potential of HDL-cholesterol raising as a strategy for improving cardiovascular outcomes, and look forward to new developments to come. On behalf of our faculty, and the delegates who participated in this exciting meeting, we hope you find these reviews of interest and of use to you in your everyday patient care.
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