Editorials

Not so “good” cholesterol

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g4664 (Published 18 July 2014) Cite this as: BMJ 2014;349:g4664
  1. Leonard Kritharides, head of cardiology
  1. 1Department of Cardiology, Concord Repatriation General Hospital, Concord, Sydney, NSW, Australia
  1. leonard.kritharides{at}sydney.edu.au

But the HDL story isn’t over yet

Low plasma concentrations of high density lipoprotein cholesterol (HDL) are a well known risk factor for coronary heart disease.1 Since the association between low HDL levels and higher risk endures in contemporary populations treated with statins,2 raising HDL concentrations has become the next frontier of “post-statin” preventive cardiovascular medicine.

In a linked paper, Keene and colleagues (doi:10.1136/bmj.g4379) present a meta-analysis of 39 randomised trials of niacin, fibrates, or cholesteryl ester transfer protein (CETP) inhibitors in over 100 000 patients.3 Although quite distinct pharmacologically, these agents share the capacity to increase plasma HDL concentrations while lowering concentrations of plasma triglycerides. They can also lower concentrations of low density lipoprotein (LDL) cholesterol, although the effect is variable.

In the new analyses, fibrates, niacin, and CETP inhibitors did not help prevent fatal cardiac events or reduce all cause morality compared with control treatments, usually a placebo. These results were consistent, regardless of whether participants were or were not taking statins. However, fibrates and niacin did reduce the risk of non-fatal myocardial infarction significantly, but only in populations not taking statins. CETP inhibitors had no significant effect on important outcomes except for an unexpected increase …

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