Treating low HDL-cholesterol in normocholesterolaemic patients with coronary disease: statins, fibrates or horses for courses?

This editorial refers to “Effects of pravastatin on coronary events in 2073 patients with low levels of both low-density lipoprotein cholesterol and high-density lipoprotein cholesterol: results from the LIPID study” 1 by D. Colquhoun et al. on page 771. A low plasma concentration of high-density lipoprotein (HDL)-cholesterol is a powerful independent risk factor for coronary heart disease (CHD). This notion is supported by consistent evidence from epidemiological, clinical and experimental studies.1 Low plasma HDL-cholesterol is frequently encountered in patients with CHD, either as part of the `atherogenic-lipid-triad' seen in central obesity or type 2 diabetes,2 or as an isolated lipoprotein abnormality of genetic origin. At present, the expert recommendation is that CHD patients who have appropriately modified their lifestyle and who have an optimal low-density lipoprotein (LDL)-cholesterol (\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \({<}\) \end{document}2.6 mmol/L) and low HDL-cholesterol (\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \({<}\) \end{document}1.05 mmol/L) be treated with HDL modifying pharmacotherapy, such as a fibrate or nicotinic acid.3 In this issue, Colquhoun et al. present a subanalysis from the Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID) study asserting that these patients could equally be treated with a statin,4 a drug usually employed to lower elevated plasma LDL-cholesterol levels.The LIPID trial is one of the largest secondary prevention trials confirming the cardiovascular benefit of treating CHD patients with a statin, specifically pravastatin 40 mg daily. In the present study, Colquhoun et al. selected a subgroup with plasma lipid entry criteria similar to volunteers in the Veterans Affairs High-Density Lipoprotein Intervention Trial (VA-HIT),5 a secondary prevention trial demonstrating the benefits of gemfibrozil (1200 mg/day) on both coronary and cerebrovascular events in CHD patients with normocholesterolaemic dyslipidaemia. Of the original 9014 LIPID subjects, 2073 were accordingly selected with entry LDL-cholesterol \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \({<}\) \end{document}3.6 mmol/L, triglyceride \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \({<}\) \end{document}3.4 mmol/L and HDL \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \({<}\) \end{document}1.0 mmol/L. In this subgroup, the relative risk reduction … *Correspondence to: Fax: +61-8-9224-0246
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