Reducing risk by raising HDL-cholesterol: the
Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Academic Hospital, Carinagasse 47, A-6807
is common among patients with cardiovascular disease.
Well-designed epidemiological studies carried out over the previous three decades
have defined the prognostic significance of low HDL-cholesterol. Indeed, a recent
evaluation of patients undergoing coronary angiography showed that factors related
to HDL-cholesterol, but not to LDL-cholesterol, were primarily responsible for
driving the elevated risk of atherosclerosis and cardiovascular events associated
with dysglycaemia within this population. Randomized intervention studies have
demonstrated significant inhibition of atherosclerosis and/or improvement in cardio-
vascular event rates with treatments that increase HDL-cholesterol (nicotinic acid or a
fibrate). Nicotinic acid is the most powerful HDL-cholesterol raising agent currently
available, and a combination of this agent with a statin facilitates simultaneous
control of both HDL-cholesterol and LDL-cholesterol. Indeed, the HDL Atherosclerosis
Treatment Study demonstrated a reduction in major cardiovascular events of 90% vs.
placebo in patients randomized to nicotinic acid þ simvastatin. In addition, patients
randomized to nicotinic acid in the Coronary Drug Project benefited from a significant
reduction in mortality after 15 years, 9 years after the trial ended. A new
prolonged-release formulation of nicotinic acid, Niaspanw, has superior tolerability
compared with immediate-release nicotinic acid and facilitates the delivery of this
therapy. The evidence base supporting intervention to correct low HDL-cholesterol
in addition to reducing LDL-cholesterol is now sufficiently strong to support the intro-
duction of this strategy into routine clinical practice.