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Treatment Target Needed for HDL Cholesterol, Expert Says


 

NEW YORK — It's time to set a target for high-density lipoprotein cholesterol in the U.S. lipid guidelines, Ernst J. Schaefer, M.D., said at the Second International Symposium on Triglycerides and HDL.

“We should try to target patients to raise their HDL cholesterol, especially if they have established heart disease. We have as much data today for HDL as we had in 1988 when we were asked to set guidelines for LDL,” said Dr. Schaefer, professor of medicine at Tufts University, Boston.

But another lipid expert who spoke at the symposium disagreed. “The time is not yet right for firm HDL guidelines,” said Antonio M. Gotto Jr., M.D., dean of the Weill Medical College of Cornell University in New York. “Results from clinical trials must confirm the benefit of treating patients with agents that primarily target HDL cholesterol.”

“It's important to treat beyond LDL cholesterol,” said Dr. Schaefer, who is also director of the lipid and heart disease prevention clinic and laboratory at Tufts-New England Medical Center. “Changes in HDL cholesterol and HDL-inclusive parameters are the strongest predictors of risk. A substantial fraction of patients don't get treated to increase their HDL. But for every 1% increase in HDL, there is about a 1%-3% reduction in coronary heart disease risk.”

Dr. Schaefer said that he was unsure of the best target level for HDL cholesterol. One option is to recommend raising levels to at least 40 mg/dL for men and 50 mg/dL for women. Another option is to set a minimum goal of more than 40 mg/dL or more than 45 mg/dL for everyone. The existing lipid goals of the National Cholesterol Education Program, the Adult Treatment Panel III, do not set a treatment strategy for patients based on their serum HDL cholesterol level.

Dr. Schaefer reviewed the evidence that documents the prognostic importance of a low level of HDL cholesterol and the risk reduction that occurs when the level of HDL cholesterol is raised. For example, in the Framingham study the strongest predictor of a person's cardiovascular risk was total cholesterol divided by HDL cholesterol. Existing guidelines in both Canada and Europe say that patients with existing coronary disease should be treated until this ratio drops below 4.0.

The results of treatment trials have documented the efficacy of several drugs to raise serum levels of HDL cholesterol and reduce the risk of cardiovascular disease events. These have included studies using cholestyramine, gemfibrozil, simvastatin, and niacin, Dr. Schaefer at the symposium, which was sponsored by the Giovanni Lorenzini Foundation.

“There is a consistent pattern that's much stronger statistically [for raising HDL cholesterol] than for [lowering] LDL cholesterol. Increasing HDL cholesterol by even a small amount may benefit patients,” Dr. Schaefer said.

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