Effective management of the type 2 diabetes patient with cardiovascular and renal disease: secondary prevention strategies after a myocardial infarction

The prevalence of type 2 diabetes mellitus has reached epidemic proportions and continues to grow in nations throughout the world. This disease is typically accompanied by other related conditions that each pose a hazard to the health of these patients and exacerbate the risk associated with diabetes for cardiovascular morbidity and mortality. Despite guideline recommendations for assessment and treatment of all of these related conditions, many patients do not achieve treatment goals. In this article, an archetypal case study is presented based on patient characteristics and conditions typically encountered in the clinic. After sustaining a myocardial infarction, the patient undergoes comprehensive evaluation and is noted to have multiple poorly controlled risk factors for cardiovascular disease and nephropathy. A multidisciplinary approach is advocated, not only to address blood glucose levels, but also to treat risk factors and comorbid conditions commonly associated with type 2 diabetes mellitus (adverse lifestyle behaviors, obesity, hypertension, albuminuria, and dyslipidemia) and complications resulting from this disease (secondary cardiovascular events, as well as nephropathy, retinopathy, and neuropathy). This comprehensive approach helps to maximize both the likelihood of reaching treatment targets for blood glucose, blood pressure, and serum lipids, and reducing the long-term risk of diabetes-related morbidity and mortality.

Clinical utility of inflammatory markers and advanced lipoprotein testing: advice from an expert panel of lipid specialists

The National Cholesterol Education Program Adult Treatment Panel guidelines have established low-density lipoprotein cholesterol (LDL-C) treatment goals, and secondary non-high-density lipoprotein (HDL)-C treatment goals for persons with hypertriglyceridemia. The use of lipid-lowering therapies, particularly statins, to achieve these goals has reduced cardiovascular disease (CVD) morbidity and mortality; however, significant residual risk for events remains. This, combined with the rising prevalence of obesity, which has shifted the risk profile of the population toward patients in whom LDL-C is less predictive of CVD events (metabolic syndrome, low HDL-C, elevated triglycerides), has increased interest in the clinical use of inflammatory and lipid biomarker assessments. Furthermore, the cost effectiveness of pharmacological intervention for both the initiation of therapy and the intensification of therapy has been enhanced by the availability of a variety of generic statins. This report describes the consensus view of an expert panel convened by the National Lipid Association to evaluate the use of selected biomarkers [C-reactive protein, lipoprotein-associated phospholipase A(2), apolipoprotein B, LDL particle concentration, lipoprotein(a), and LDL and HDL subfractions] to improve risk assessment, or to adjust therapy. These panel recommendations are intended to provide practical advice to clinicians who wrestle with the challenges of identifying the patients who are most likely to benefit from therapy, or intensification of therapy, to provide the optimum protection from CV risk.

Niacin extended-release/simvastatin combination therapy produces larger favorable changes in high-density lipoprotein particles than atorvastatin monotherapy

Background

The purpose of this research was to compare the effects of niacin extended-release in combination with simvastatin (NER/S) versus atorvastatin monotherapy on high-density lipoprotein (HDL) particle number and size in patients with hyperlipidemia or dyslipidemia from the SUPREME study.

Methods

This was a post hoc analysis of patients (n = 137) who completed the SUPREME study and who had lipid particle number and size measurements at both baseline and at week 12 by nuclear magnetic resonance spectroscopy. Following ≥4 weeks without lipid-modifying therapy (washout period), the patients received NER/S 1000/40 mg/day for 4 weeks followed by NER/S 2000/40 mg/day for 8 weeks, or atorvastatin 40 mg/day for 12 weeks. Median percent changes in HDL particle number and size from baseline to week 12 were compared between the NER/S and atorvastatin treatment groups using the Wilcoxon rank-sum test. Distribution of HDL particle subclasses at week 12 was compared between the treatment groups using the Cochran–Mantel–Haenszel test.

Results

Treatment with NER/S resulted in a significantly greater percent reduction in small HDL particle number at week 12 compared with atorvastatin monotherapy (−1.8% versus 4.2%, P = 0.014), and a numerically greater percent increase in large HDL particle number (102.4% versus 39.2%, P = 0.078) compared with atorvastatin monotherapy. A significantly greater percent increase in HDL particle size from baseline at week 12 was observed with NER/S compared with atorvastatin (6.0% versus 1.3%, P < 0.001). NER/S treatment also resulted in a significant shift in HDL particle size from small and medium at baseline to large at week 12 (P < 0.0001).

Conclusion

Treatment with NER/S resulted in larger favorable changes in number and size of HDL particle subclasses compared with atorvastatin monotherapy, including a numerically greater increase in number of large HDL particles, and a significantly greater decrease in number of small HDL particles compared with atorvastatin monotherapy. In addition, NER/S treatment resulted in a significant change in HDL particle size distribution from small and medium to large.

Impact of lung transplantation on serum lipids in COPD

BACKGROUND

Severe chronic obstructive pulmonary disease is associated with high HDL cholesterol (HDL-C). We sought to examine the effect of lung transplantation on lipid profiles in patients with COPD.

METHODS

We analyzed 101 lung transplant recipients in a retrospective cohort of patients from two centers in whom lipid values were available both before as well as after transplantation. Sixty-one subjects were transplanted for severe COPD (93% GOLD stage 4).

RESULTS

Eighty-nine percent of subjects with COPD exhibited a decline in HDL-C. Median decline for the COPD cohort was 25 mg/dL (IQR 12-38 mg/dL, p < 0.0001). Non-COPD subjects exhibited no significant changes in HDL-C. Other lipid changes in the COPD cohort included a rise in triglycerides of 70 mg/dL (IQR 35 to 140, p < 0.0001). Decreases in HDL-C levels were independent from the rise in triglyceride levels. Neither LDL-C nor non-HDL-C demonstrated significant changes. Subjects with greater increases in prednisone exposure post-transplant exhibited lesser declines in HDL-C. Compared with tacrolimus, cyclosporine had no effect on observed changes in HDL-C or triglycerides, but was associated with a greater median rise in LDL-C.

CONCLUSIONS

In patients with COPD, lung transplantation results in reductions in the serum levels of HDL-C. These changes are not observed in patients undergoing lung transplantation for diagnoses other than COPD.

Antisense therapy and emerging applications for the management of dyslipidemia

BACKGROUND

Because a significant percentage of patients who require high-dose statin therapy for dyslipidemia experience treatment-related muscle symptoms and an inconsistent clinical response, alternative or adjunctive approaches to the management of dyslipidemia are needed. One alternative approach, antisense therapy, may offer an effective and well-tolerated option for patients not satisfactorily responsive to or intolerant to standard pharmacologic dyslipidemia therapies.

OBJECTIVE

This review provides an overview of antisense technology and its potential role in the management of dyslipidemia.

METHODS

Source material was obtained primarily from the published literature identified through a search of the PubMed database.

RESULTS

Antisense technology is an evolving approach to therapy that has gone through a series of refinements to enhance molecular stability, potency, and tolerability. Mipomersen is an antisense molecule capable of producing clinically meaningful reductions in low-density lipoprotein cholesterol in patients with severe familial hypercholesterolemia. Further long-term clinical studies are required to more clearly quantify its impact on risk for cardiovascular events and establish whether it increases risk for hepatosteatosis.

CONCLUSION

Antisense therapy represents a potentially effective and well-tolerated emerging treatment modality for numerous diseases. In the treatment of hypercholesterolemia, the antisense therapy mipomersen may provide a possible treatment option for patients with treatment-resistant dyslipidemia.

Pharmacomodulation of high-density lipoprotein metabolism as a therapeutic intervention for atherosclerotic disease

The high-density lipoproteins (HDLs) are produced by the liver and small intestine as well as on the surface of lipid-enriched macrophages in the subendothelial space of arterial walls. Unlike the apo B100-containing lipoproteins, the HDLs are uniquely antiatherogenic. Based on prospective observational studies performed throughout the world, there is a consistent inverse relationship between serum levels of HDLs and risk for cardiovascular events: low levels of high-density lipoprotein-cholesterol (HDL-C) are associated with increased risk, whereas high levels are usually associated with reduced risk for myocardial infarction, ischemic stroke, and cardiovascular mortality. Post hoc analyses of a number of studies using statins and fibrates have shown that raising serum HDL-C correlates with a reduction in risk for cardiovascular morbidity and mortality. Given these observations, enormous resources are being committed to the development of novel means by which to pharmacologically increase rates of HDL biosynthesis, modulate the functionality of HDL, and to promote reverse cholesterol transport with intravenous infusions of HDL particles.

Combination of niacin extended-release and simvastatin results in a less atherogenic lipid profile than atorvastatin monotherapy

OBJECTIVE

To compare the effects of combination niacin extended-release + simvastatin (NER/S) versus atorvastatin alone on apolipoproteins and lipid fractions in a post hoc analysis from SUPREME, a study which compared the lipid effects of niacin extended-release + simvastatin and atorvastatin in patients with hyperlipidemia or mixed dyslipidemia.

PATIENTS AND METHODS

Patients (n = 137) with dyslipidemia (not previously receiving statin therapy or having discontinued any lipid-altering treatment 4-5 weeks prior to the study) received NER/S (1000/40 mg/day for four weeks, then 2000/40 mg/day for eight weeks) or atorvastatin 40 mg/day for 12 weeks. Median percent changes in apolipoprotein (apo) A-1, apo B, and the apo B:A-I ratio, and nuclear magnetic resonance lipoprotein subclasses from baseline to week 12 were compared using the Wilcoxon rank-sum test and Fisher's exact test.

RESULTS

NER/S treatment produced significantly greater percent changes in apo A-I and apo B:A-I, and, at the final visit, apo B < 80 mg/dL was attained by 59% versus 33% of patients, compared with atorvastatin treatment (P = 0.003). NER/S treatment resulted in greater percent reductions in calculated particle numbers for low-density lipoprotein (LDL, 52% versus 43%; P = 0.022), small LDL (55% versus 45%; P = 0.011), very low-density lipoprotein (VLDL) and total chylomicrons (63% versus 39%; P < 0.001), and greater increases in particle size for LDL (2.7% versus 1.0%; P = 0.007) and VLDL (9.3% versus 0.1%; P < 0.001), compared with atorvastatin.

CONCLUSION

NER/S treatment significantly improved apo A-I levels and the apo B:A-I ratio, significantly lowered the number of atherogenic LDL particles and VLDL and chylomicron particles, and increased the mean size of LDL and VLDL particles, compared with atorvastatin.

Drug treatment of hyperlipidaemia: a guide to the rational use of lipid-lowering drugs

Mammalian sterol and lipid metabolism depends on a large number of highly evolved biochemical and histological processes responsible for the absorption, distribution and steady-state anabolic/catabolic handling of these substances. Lipoproteins are complex polymolecular assemblies comprising phospholipids, cholesterol and cholesterol esters, triglycerides and a variety of apolipoproteins. The primary function of lipoproteins is to facilitate the systemic distribution of sterols and lipids. Abnormalities in lipoprotein metabolism are quite common and are attributable to a large number of genetic mutations, metabolic derangements such as insulin resistance or thyroid dysfunction, and excess availability of cholesterol and fat from dietary sources. Dyslipidaemic states facilitate endothelial dysfunction and atherogenesis. Dyslipidaemia is recognized as a risk factor for cardiovascular disease in both men and women, and people of all racial and ethnic groups throughout the world. Dyslipidaemia is modifiable with dietary change and the use of medications that impact on lipid metabolism through a variety of mechanisms. Reducing atherogenic lipoprotein burden in serum is associated with significant and meaningful reductions in risk for a variety of cardiovascular endpoints, including myocardial infarction, ischaemic stroke, development of peripheral arterial disease and mortality. This review provides an overview on how to best position lipid-lowering drugs when attempting to normalize serum lipid profiles and reduce risk for cardiovascular disease. HMG-CoA reductase inhibitors (statins) are widely accepted to be the agents of choice for reducing serum levels of low-density lipoprotein cholesterol (LDL-C) in both the primary and secondary prevention settings. Ezetimibe and bile acid sequestrants are both effective agents for reducing LDL-C, either used alone or in combination with statins. The statins, fibric acid derivatives (fibrates) and niacin raise high-density lipoprotein cholesterol to different extents depending upon genetic and metabolic background. Fibrates, niacin and omega-3 fish oils are efficacious therapies for reducing serum triglycerides. Combinations of these drugs are frequently required for normalizing mixed forms of dyslipidaemia.

Pleiotropic effects of angiotensin receptor blockers: addressing comorbidities by optimizing hypertension therapy

The efficacy of angiotensin receptor blockers (ARBs) in the management of hypertension is well established. Whether these agents induce pleiotropic effects that promote the amelioration of vascular disorders independent of blood pressure reduction remains controversial. This review examines preclinical and clinical data that highlight a potentially important role for ARBs in several common vascular disorders, including cardiovascular, cerebrovascular, renal, and metabolic disorders. The preponderance of evidence suggests that some of the benefits derived from ARBs might improve outcomes in these disorders by actions that extend beyond blood pressure reduction. This review also identifies some potentially important differences in the mechanism of action between ARBs and angiotensin-converting enzyme inhibitors that may have clinical significance in the management of vascular diseases.

The role of statins in managing diabetic dyslipidemia

The common lipid abnormalities associated with T2DM confer substantial CV risk. Statins are a safe and well-established treatment option for lowering this atherogenic burden and improving outcomes in this patient population. Nonetheless, many patients with T2DM are not receiving a statin, and even those who receive treatment may not be achieving recommended lipid targets. Strategies must be implemented to improve the quality of care for these patients who are at high risk for a primary or secondary CV event.

Should we target HDL cholesterol level in lowering cardiovascular risk?

In prospective observational studies and retrospective case control studies performed throughout the world, low serum levels of high-density lipoprotein cholesterol (HDL-C) are consistently associated with increased risk for all forms of atherosclerotic disease and its clinical sequelae, including myocardial infarction, stroke, and sudden death. In contrast, high serum levels of this lipoprotein are associated with reduced risk for these outcomes. The metabolism of high-density lipoproteins (HDLs) is complex, and a very large number of genetic polymorphisms influence the serum level of HDL particles in any given individual. A significant question in cardiovascular medicine is whether or not prospectively raising HDL in patients at risk is associated with significant reductions in cardiovascular events and rates of atherosclerotic disease progression. A recent comprehensive meta-analysis that incorporated the results of 108 prospective clinical trials suggests that the answer to this question is "no" with currently available lipid modifying therapies. However, a number of individual clinical trials and other meta-analyses suggest that, in fact, raising HDL does beneficially impact risk for cardiovascular events and slows progression or even reverses atherosclerosis. HDL appears to antagonize atherogenesis and drive a number of vasculoprotective phenomena. It has antioxidative, anti-proliferative, anti-thrombotic, and anti-inflammatory properties and potentiates reverse cholesterol transport. Under some conditions, the proteosome of HDL can change, rendering it pro-inflammatory and pro-oxidative. This paper explores many of the key questions surrounding HDL-C and why probing its efficacy may not be entirely amenable to a meta-analysis. Numerous drugs are in development which have the capacity to raise HDL-C dramatically. It is hoped that these agents will be able to provide us with a more definitive answer about the clinical efficacy of raising HDL-C, and what specific approaches will be necessary in patients with specific genetic and metabolic backgrounds in both the primary and secondary prevention settings.

Niacin and fibrate use among patients with high triglycerides and low high-density lipoprotein cholesterol

BACKGROUND

National guidelines recommend treating low HDL and/or high triglycerides (TG) with adjunctive therapy that supplements statin monotherapy in patients with multiple cardiovascular disease (CVD) risk factors. Niacin and fibrates have been shown in clinical trials to be effective as adjunctive therapy for these lipid abnormalities.

OBJECTIVE

To evaluate the pharmacologic treatment of low HDL and high TG in real-world practice by assessing a large managed-care population with CVD risk factors enrolled in a commercial health plan.

RESEARCH DESIGN AND METHODS

Complete lipid panel results (LDL, HDL, TG) obtained between 1/1/2006 and 12/31/2006 (index lab) were available for all participants. Subjects were observed 180 days pre-index to determine which CVD risk factors were present (male aged 45+, female 55+, coronary heart disease, hypertension, diabetes mellitus). Patients whose LDL was at goal but who had low HDL and high TG were assessed for lipid treatment status by evaluating outpatient pharmacy claims 6 months pre- and post-index.

RESULTS

Treatment with any lipid therapy increased for all risk groups, and by total risk factors, from pre-index to post-index. Use of fibrates and niacin, alone or in combination with a statin, also increased for all risk groups, and by total risk factors as well, but was below expectations based on guideline recommendations. For example, among patients with 4 risk factors, <20% of patients with low HDL/high TG received niacin and/or a fibrate post-index date.

CONCLUSIONS

Our results indicate that in actual clinical practice, niacin and fibrates are underutilized in the treatment of low HDL and high TG. The findings of this study must be considered within the limitations of database analysis as claims data are collected for the purpose of payment and not research.

Clinical insights from the Fenofibrate Intervention and Event Lowering in Diabetes study: a community practice perspective

Achieving adequate control of cardiovascular risk in type 2 diabetes mellitus (DM) is crucially important; however, the atherogenic dyslipidaemia (including low high-density lipoprotein cholesterol and hypertriglyceridaemia) typically encountered in type 2 DM is often managed inadequately. Evidence from the Fenofibrate Intervention and Event Lowering in Diabetes study suggests that fenofibrate reduces the risk of long-term macrovascular and microvascular type 2 diabetic complications, especially in patients demonstrating features of the metabolic syndrome. Fenofibrate represents a useful treatment option for controlling cardiovascular risk in type 2 diabetes patients in the community setting.

Dyslipidemia treatment of patients with diabetes mellitus in a US managed care plan: a retrospective database analysis

Background

To evaluate real-world pharmacologic treatment of mixed dyslipidemia in patients with diabetes mellitus (DM).

Methods

All commercial health plan members in a large US managed care database with complete lipid panel results (HDL-C, LDL-C, TG) between 1/1/2006 and 12/31/2006 were identified (N = 529,236). DM patients (N = 53,679) with mixed dyslipidemia were defined as having any 2 suboptimal lipid parameters (N = 28,728). Lipid treatment status 6 months pre- and post-index date was determined using pharmacy claims for any lipid therapy.

Results

Post-index, 41.1% of DM patients with 2 abnormal lipid parameters and 45.1% with 3 abnormal lipid parameters did not receive lipid-modifying treatment. Post-index treatment rates were 57.4%, 63.6%, and 66.4% for patients with LDL-C, HDL-C, and TG in the most severe quartiles, respectively. Statin monotherapy was the primary lipid-modifying regimen prescribed (54.8% and 47.8% of patients with any 2 and all 3 lipids not at goal, respectively). Less than 30% of treated patients received combination therapy.

Conclusion

Over 40% of DM patients with mixed dyslipidemia received no lipid-modifying therapy during the follow-up period. Those who were treated were primarily prescribed statin monotherapy. This study suggests that DM patients are not being treated to ADA-suggested targets.

Novel therapies for increasing serum levels of HDL

The protectiveness of elevated HDL-C against CHD and its long-term sequelae is a subject of intense investigation throughout the world. HDL has the capacity to modulate a large number of atherogenic mechanisms, such as inflammation, oxidation, thrombosis, and cell proliferation. Among lipoproteins, HDL is also unique, in that it promotes the mobilization and clearance of excess lipid via the series of reactions collectively termed "reverse cholesterol transport." Numerous therapeutic agents are being developed in an attempt to modulate serum levels of HDL-C as well as its functionality. This article discusses the development of newer treatments targeted at raising HDL-C and HDL particle numbers to reduce residual risk in patients at risk for CHD.

Subclinical atherosclerosis: what it is, what it means and what we can do about it

Atherosclerosis is a chronic, progressive, inflammatory disease with a long asymptomatic phase. Disease progression can lead eventually to the occurrence of acute cardiovascular events such as myocardial infarction, unstable angina pectoris and sudden cardiac death. While the disease is still in a subclinical stage, however, the presence of atherosclerosis can be identified by several methods, including coronary angiography, intravascular ultrasonography, B-mode ultrasonography, computed tomography and magnetic resonance imaging. Based on the results of imaging studies, statin therapy can slow, halt or even reverse the progression of atherosclerotic disease, depending on the intensity of treatment. Whether to screen and treat patients for subclinical atherosclerosis remains controversial. Although atheromatous plaque burden reduction has not yet been definitively correlated with significant decreases in risk for acute coronary events in asymptomatic patients, statin therapy contributes significantly to the risk reduction observed in clinical trials in patients with and without overt coronary disease.

Implications of recent statin trials for primary care practice

3-Hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins) are the first-line treatment for dyslipidemia and the results of large statin trials have a significant impact on guidelines for cardiovascular disease (CVD) management, such as those set by the National Cholesterol Education Program Adult Treatment Panel. The benefit of statin therapy in CVD prevention has traditionally been demonstrated in clinical trials by the superior efficacy of statins vs placebo in lowering low-density lipoprotein cholesterol (LDL-C) and preventing hard coronary heart disease (CHD) outcomes including myocardial infarction and CHD death. However, due to earlier and improved treatment of CVD, the clinical manifestations of atherosclerosis are changing and other forms of CVD are now thought to predominate (such as revascularization and stroke). These changes in how CVD manifests in the patient population may have consequences for selection of endpoints when designing future clinical trials. Recent statin trials have also demonstrated the early and improved clinical benefit of lowering LDL-C beyond traditional goals with intensive statin therapy vs more moderate lipid-lowering therapy. This review assesses the impact of early statin trials on current CVD management guidelines, summarizes results of recent landmark statin trials, and evaluates the potential implications of these studies for future clinical trials and CVD management guidelines.

Gender Differences in Adhering to National Guidelines in a Community Lipid Clinic

The aggressive treatment of hypercholesterolemia improves morbidity and mortality in patients with a history of cardiovascular disease irrespective of gender. Electronically tracked data on 4324 patients enrolled in a community lipid clinic were analyzed for gender differences in lipid values and adherence to national guidelines in lipid management. Women were older, more likely to be diabetic and/or hypertensive, and have a family history of coronary heart disease. Women also had higher initial total cholesterol, low-density lipoprotein, and triglyceride levels and were more likely to be at goal at entry for high-density lipoprotein. Men were more likely to have coronary heart disease and lower high-density lipoprotein and were more likely to be at goal at entry for triglyceride level. There were no gender differences in low-density lipoprotein at goal at entry or rate of current smoking. All lipid parameters appeared better with age, irrespective of gender. More men than women reached goal for their low-density lipoprotein (61.5% vs 51.7%) and triglyceride (36.9% vs 25.1%) levels, whereas more women than men reached goal for their high-density lipoprotein (33.1% vs 22.2%). The authors conclude that there are significant gender differences in lipid values at entry to a community lipid clinic and in achieving National Cholesterol Education Program targets following the initiation of therapy. A possible gender-independent survivorship effect exists for low-density lipoprotein and high-density lipoprotein.

Reducing cardiovascular risk by targeting high-density lipoprotein cholesterol

Although lowering low-density lipoprotein (LDL) cholesterol with statins can substantially reduce cardiovascular morbidity and mortality, many treated patients retain a residual risk for cardiovascular events. Low levels of high-density lipoprotein (HDL) cholesterol may underpin this residual risk and may represent an additional target for intervention. Several new therapies for substantially increasing HDL cholesterol levels are under investigation, including cholesteryl ester transfer protein (CETP) inhibitors, apolipoprotein A-I mimetics and recombinant HDL, liver X receptor (LXR) agonists, and peroxisome proliferator-activated receptor (PPAR) agonists. Combining new HDL cholesterol-elevating agents with existing LDL cholesterol-lowering agents may improve the cardiovascular risk reductions currently attainable.

The CARDS trial: diabetic patients dealt a winning hand

Until recently, the role of statin therapy in diabetic patients without clinical signs or symptoms of coronary heart disease had been inadequately defined. The Collaborative Atorvastatin Diabetes Study (CARDS) is a prospective, randomized, placebo-controlled trial designed to compare the effects of atorvastatin with placebo in preventing primary coronary events in diabetic patients. After a median of only 3.9 years (the study was terminated approximately 2 years early due to the magnitude of benefit attributable to atorvastatin therapy), risk for major cardiovascular events was decreased by 37%, acute coronary heart disease-related events were also reduced by 36%, coronary revascularizations by 31%, and stroke by 48%. Benefit emerged within 1 year of initiating therapy.

Cholesterol absorption blockade with ezetimibe

The reduction of circulating atherogenic lipoproteins through lifestyle modification and pharmacologic intervention is an important therapeutic goal in patients at risk for acute cardiovascular events. A large number of clinical trials have demonstrated that the reduction of low-density lipoprotein cholesterol (LDL-C) is associated with significant decreases in the incidence of all cause mortality, stroke, fatal and nonfatal myocardial infarction, and the need for revascularization with coronary artery bypass grafting and percutaneous transluminal coronary angioplasty. Therapy with 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors (i.e., statins) are the agents of choice for treating a variety of dyslipidemias, particularly when LDL-C levels are elevated. The statins are highly efficacious; however, not all patients are able to tolerate the higher doses of these medications due to adverse side-effects such as hepatoxicity and myotoxicity. Moreover, many patients cannot achieve their various lipoprotein targets at even the highest doses of these medications. Ezetimibe is a novel cholesterol absorption inhibitor that blocks the translocation of dietary and biliary cholesterol from the gastrointestinal lumen into the intracellular space of jejunal enterocytes. Ezetimibe undergoes enterohepatic recirculation with minimal systemic exposure and not does not adversely impact the pharmacokinetic profile of statins. Ezetimibe significantly reduces serum LDL-C. It is safe when used as monotherapy or when used in combination with statins. Ezetimibe is indicated in the management of hyperlipidemia, familial hypercholesterolemia, and sitosterolemia and significantly increases the percentage of patients able to reach their lipid-lowering goals.