Open Access‘Trig‐onometry’: non‐high‐density lipoprotein cholesterol as a therapeutic target in dyslipidaemia
Author(s) -
Jacobson T. A.
Publication year - 2011
Publication title -
international journal of clinical practice
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.756
H-Index - 98
eISSN - 1742-1241
pISSN - 1368-5031
DOI - 10.1111/j.1742-1241.2010.02547.x
Subject(s) - medicine , niacin , ezetimibe , fibrate , fenofibrate , lipoprotein , cholesterol , endocrinology , clinical trial , hypertriglyceridemia , risk factor , statin , triglyceride , gastroenterology
Summary Targeting elevations in low‐density lipoprotein cholesterol (LDL‐C) remains the cornerstone of cardiovascular prevention. However, this fraction does not adequately capture elevated triglyceride‐rich lipoproteins (TRLs; e.g. intermediate‐density lipoprotein, very low density lipoprotein) in certain patients with metabolic syndrome or diabetic dyslipidaemia. Many such individuals have residual cardiovascular risk that might be lipid/lipoprotein related despite therapy with first‐line agents (statins). Epidemiological evidence encompassing > 100,000 persons supports the contention that non‐high‐density lipoprotein cholesterol (non‐HDL‐C) is a superior risk factor vs. LDL‐C for incident coronary heart disease (CHD) in certain patient populations. In studies with clinical end‐points evaluated in the current article, a 1 : 1 to 1 : 3 relationship was observed between reductions in non‐HDL‐C and in the relative risk of CHD after long‐term treatment with statins, niacin (nicotinic acid) and fibric‐acid derivatives (fibrates); this relationship increased to 1 : 5 to 1 : 10 in smaller subgroups of patients with elevated triglycerides and low HDL‐C levels. Treatment with statin‐, niacin‐, fibrate‐, ezetimibe‐, and omega 3 fatty acid‐containing regimens reduced non‐HDL‐C by approximately 9–65%. In a range of clinical trials, long‐term treatment with these agents also significantly decreased the incidence of clinical/angiographic/imaging efficacy outcome variables. For patients with dyslipidaemia, consensus guidelines have established non‐HDL‐C treatment targets 30 mg/dl higher than LDL‐C goals. Ongoing prospective randomised controlled trials should help to resolve controversies concerning (i) the clinical utility of targeting non‐HDL‐C in patients with dyslipidaemia; (ii) the most efficacious and well‐tolerated therapies to reduce non‐HDL‐C (e.g. combination regimens); and (iii) associations between such reductions and clinical, angiographic, and/or imaging end‐points.