The realities of dyslipidaemia: what do the studies tell us?

Well-designed studies have established the benefits of statins in populations with widely differing overall cardiovascular risk. Statins reduce LDL-cholesterol in all of these populations, in some cases to a level well below guideline targets. The effects of statins on cardiovascular outcomes are remarkably similar between studies, with the incidence of cardiovascular events reduced relative to placebo by not more than similar to 40% in any study and usually by similar to 10-30%. Addressing other cardiovascular risk factors will be necessary to generate additional benefits. Atherosclerosis is increasingly considered an inflammatory disease, and reducing markers of inflammation, such as C-reactive protein, may prove beneficial. However, intervention with agents that increase HDL-cholesterol is already supported by substantial clinical evidence. A number of well-designed evaluations of fibrates and nicotinic acid, which act mainly by raising levels of HDL-cholesterol, have demonstrated significant improvements in outcomes in populations at high risk of cardiovascular events. Combinations of nicotinic acid with a statin have been shown to halt or reverse the progression of atherosclerosis, in the HDL Atherosclerosis Treatment Study (HATS) and in the Investigation of the Treatment Effects of Reducing Cholesterol (ARBITER) 2 trial. Nicotinic acid-statin combination therapy has produced the largest improvements in clinical outcomes so far achieved, with a reduction in cardiovascular events of 60-90% relative to placebo in HATS. Nicotinic acid-based combinations are a rational and an evidence-based approach to improve cardiovascular outcomes to a greater extent than is currently possible with statins alone.