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HDL: Why it’s so important

Q: What is the most common lipid abnormality that causes heart attack?

A: Low HDL cholesterol

That’s right—it’s not high LDL cholesterol. Look at the HDL levels in people with heart attacks. More than likely, people with heart attacks have low HDL of 40 mg/dl or less, and LDL will be in the 100–160 mg/dl range (i.e., in the middle range, neither high nor low). Should these people be treated with an LDL-lowering agent alone? Will lowering LDL eliminate the risk posed by low HDL?

The evidence suggests that both abnormalities need to be treated. And in the patients who already have a low LDL, strategies to raise HDL should be initiated. The combined strategy of lowering LDL and raising HDL can, in fact, be a powerful means of preventing future coronary events and achieving plaque regression. In this report, we discuss the very important findings of Dr. Greg Brown’s “HATS” Trial, conducted at the University of Washington.

The HDL-Atherosclerosis Treatment Study (HATS) trial enrolled 160 patients (149 males), all of whom had documented coronary disease. Coronary plaque was measured with heart catheterization. There were four treatment arms: simvastatin (Zocor) + niacin, placebo, simvastatin + niacin +anti-oxidant vitamins, and anti-oxidant vitamins alone.

The anti-oxidant treatment arms proved of no value in lowering coronary events or achieving plaque regression. Let’s focus on the HDL observations. This boils down to a comparison of two groups: the placebo group vs. the simvastatin + niacin. Simvastatin therapy was adjusted to achieve an LDL of 90 mg/dl or lower; niacin was adjusted to achieve an increase in HDL of 10 mg/dl. As expected, the treatment arm patients achieved a mildly greater reduction in plaque progression.

But what is eye-opening in this study is the magnitude of reduction of events comparing the simvastatin + niacin group to the placebo group: There was a 90% reduction in death and myocardial infarction (12 events placebo;1 event simvastatin + niacin) over three years. In other words, coronary events were nearly shut off.

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Copyright 2005, Track Your Plaque.