Beyond statin therapy: why we need new thinking

ABSTRACT

Many current treatment guidelines aimed at the prevention of cardiovascular events focus on low-density lipoprotein cholesterol (LDL‐C) targets when addressing dyslipidaemia, and hence, indirectly at least, encourage the use of statin therapy. While this strategy shows marked clinical benefit, reducing cardiovascular risk by approximately 30%, there remains scope for greater treatment success. Recent analyses of data from epidemiological studies such as the Prospective Cardiovascular Münster (PROCAM) highlighted the importance of other lipid parameters of risk, such as a deficit of plasma high-density lipoprotein cholesterol (HDL‐C) or an excess of lipoprotein (a) [Lp(a)]. HDL has been shown to be operative in a wide range of atheroprotective mechanisms beyond its well known role in reverse cholesterol transport, while Lp(a) is known to increase atherothrombotic responses. Both HDL and Lp(a) levels interact with other parameters of risk, including LDL‐C, such as to greatly influence an individual's global risk. As a consequence, the International Task Force for Prevention of Coronary Heart Disease has recently produced guidelines that consider an individual's risk to result from both classical and emerging risk factors. HDL‐C raising is advocated as a treatment strategy for at-risk patients with fasting triglyceride levels ≥ 200 mg/dL (≥ 2.3 mmol/L) and HDL‐C levels < 35 mg/dL (< 0.9 mmol/L). This strategy is supported by prospective epidemiological evidence. Lp(a) has not been specifically tested as a target for intervention, but it is included in the new guidelines where it is regarded as an important modifier of global risk.

Key words::

• Cardiovascular events
• Guidelines
• High-density lipoprotein cholesterol
• Lipoprotein (a)
• PROCAM
• Risk factor
• Statin