Correlation of non-high-density lipoprotein cholesterol with apolipoprotein B: effect of 5 hydroxymethylglutaryl coenzyme A reductase inhibitors on non-high-density lipoprotein cholesterol levels

Prognostic role of apolipoproteins on long-term major adverse cardiac events after percutaneous coronary intervention

BACKGROUND/PURPOSE

Apolipoprotein (apo) levels are associated with coronary risk. However, the relationship between apo levels after percutaneous coronary intervention (PCI) and long-term major adverse cardiac events (MACEs) remains unclear. We aimed to investigate the association between lipid levels, including apo, at follow-up, and long-term MACEs in patients undergoing PCI.

METHODS/MATERIALS

In total, 241 patients who underwent PCI between January 2004 and August 2008 were included in this study. MACEs were defined as cardiac death, acute coronary syndrome, or coronary revascularization of new lesions. The primary endpoint was MACE, and the secondary endpoint was a composite of cardiac death and acute coronary syndrome.

RESULTS

During a mean follow-up period of 2079 days, the following cardiovascular events occurred in 78 patients: cardiovascular death (n = 1), non-fatal acute myocardial infarctions (n = 10), and revascularizations of new lesions (n = 67). Multivariate cox's proportional hazards analysis showed that the apo B level was an independent risk factor for MACEs (hazard ratio 1.11, 95 % confidence interval 1.03-1.20; P = 0.009). In the Kaplan-Meier estimation for primary endpoints, significant differences were observed in the apo B level and apo B/apo A1 ratio (P = 0.04 and P = 0.004, respectively). However, there was no difference in the LDL-C level and LDL-C/HDL-C ratio. At the secondary endpoint, only the apo B/apo A1 ratio was a prognostic factor (P = 0.007).

CONCLUSIONS

In the long-term cardiovascular events of patients undergoing PCI, the apo B level and apo B/apo A1 ratio were more valuable prognostic factors for cardiovascular events compared to the LDL-C level and LDL-C/HDL-C ratio.

Current and future options in cholesterol lowering treatments

The relative risk reduction of cardiovascular events is proportional to the absolute reduction in LDL-C levels, the primary target of therapy, no matter the way of reduction. During the last decades, the therapeutic regimens for reducing the LDL-C levels have been immerged and improved, with favorable effects on the atherosclerotic process and clinical benefits of various cardiovascular outcomes. From a practical view of point, this review is focusing only on the current available lipid lowering agents: statins, ezetimibe, anti PCSK9 monoclonal antibodies, the small interfering RNA (siRNA) agent, Inclisiran, and Bempedoic acid. The recent changes in lipid lowering regimens, including the early combination of lipid lowering agents and "Low LDL-C" levels <30 mg/dL for high/very high cardiovascular risk patients will also be discussed.

The Role of Structure and Biophysical Properties in the Pleiotropic Effects of Statins

Statins are a class of drugs used to lower low-density lipoprotein cholesterol and are amongst the most prescribed medications worldwide. Most statins work as a competitive inhibitor of 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase (HMGR), but statin intolerance from pleiotropic effects have been proposed to arise from non-specific binding due to poor enzyme-ligand sensitivity. Yet, research into the physicochemical properties of statins, and their interactions with off-target sites, has not progressed much over the past few decades. Here, we present a concise perspective on the role of statins in lowering serum cholesterol levels, and how their reported interactions with phospholipid membranes offer a crucial insight into the mechanism of some of the more commonly observed pleiotropic effects of statin administration. Lipophilicity, which governs hepatoselectivity, is directly related to the molecular structure of statins, which dictates interaction with and transport through membranes. The structure of statins is therefore a clinically important consideration in the treatment of hypercholesterolaemia. This review integrates the recent biophysical studies of statins with the literature on the physiological effects and provides new insights into the mechanistic cause of statin pleiotropy, and prospective means of understanding the cholesterol-independent effects of statins.

Assessment of apolipoprotein B/apolipoprotein A-I ratio in non-ST segment elevation acute coronary syndrome patients

Background

The apolipoprotein B/apolipoprotein A-I ratio was shown to be strongly related to the risk of myocardial infarction in several large-scale studies. The current study aimed at exploring the diagnostic and short-term prognostic values of apolipoprotein B/apolipoprotein A-I ratio in patients presenting with non-ST segment elevation acute coronary syndrome. One hundred patients with non-ST segment elevation acute coronary syndrome were prospectively enrolled, in addition to a matched group of 100 patients with chronic stable angina. Serum levels of total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides, and apolipoproteins B and A-I were quantified in both groups. Patients with non-ST segment elevation acute coronary syndrome underwent coronary angiography.

Results

The mean age of the study population was 57 ± 6 years, 65% being males. The non-ST segment elevation acute coronary syndrome group showed significantly unfavorable lipid profile parameters, including apolipoprotein B/apolipoprotein A-I ratio. Higher apolipoprotein B/apolipoprotein A-I ratio was associated with more coronaries showing significant stenosis and more complex lesion morphology. Receiver operating characteristic curve analysis reached an optimal cut-off value of 0.93 for diagnosis of non-ST segment elevation acute coronary syndrome (sensitivity 70% and specificity 88%) and 0.82 for predicting the presence of multi-vessel disease (sensitivity 90% and specificity 97%).

Conclusion

Apolipoprotein B/apolipoprotein A-I ratio is a useful tool of risk assessment in patients presenting with non-ST segment elevation acute coronary syndrome including prediction of coronary multivessel affection.

Apolipoprotein B/apolipoprotein A-I ratio was shown to be strongly related to risk of myocardial infarction. Higher ratios of apolipoprotein B/apolipoprotein A-I were recorded in NSTE-ACS patients (versus stable angina patients). Higher apolipoprotein B/apolipoprotein A-I ratios were associated with more diseased coronaries and complex lesions. Apolipoprotein B/apolipoprotein A-I ratio is a useful tool for acute risk assessment in cardiac ischemic patients.

Non-HDL cholesterol as a therapeutic goal

Although cholesterol linked to low-density lipoproteins (c-LDL) is well established as a risk factor for cardiovascular disease, there is often a more complex dyslipidaemia pattern that contributes to the formation of atherosclerotic plaque. Non-HDL cholesterol (c-NO-HDL) is used to estimate the total amount of atherogenic lipoproteins in plasma, some of which are not usually determined in daily clinical practice. c-NO-HDL is easily calculated from the subtraction of total plasma cholesterol from the cholesterol content carried by high density lipoproteins. The c-NO-HDL has a predictive value superior to that of C-LDL to estimate the risk of major cardiovascular events in epidemiological studies. Genetic studies by analysis of the complete genome, together with those based on Mendelian randomisation, point to the aetiological character of c-NO-HDL on ischaemic heart disease (IHD). Intervention studies, and the meta-analyses derived from them, close the causal circle between c-NO-HDL and IHD, by demonstrating that any intervention that decreases the concentrations of the former reduces the incidence of arteriosclerotic heart disease. The European ESC/EAS 2016 guide for the management of dyslipidaemia considers c-NO-HDL as a therapeutic target with a Class IIa recommendation (should be performed) Level B (data from a single randomised clinical trial [RCT]) or from several non-RCTs), and sets its target at less than 100 or 130mg/dL for those patients with very high risk or high risk, respectively. These achievable c-NO-HDL values are easily calculated by adding 30mg/dL to the c-LDL targets.

Low-Volume High-Intensity Interval Training (HIIT) versus Moderate-Intensity Continuous Training on Body Composition, Cardiometabolic Profile and Physical Capacity in Older Women

OBJECTIVES

To compare the effect of low-volume HIIT to moderate-intensity aerobic training (MICT) on fat mass, cardiometabolic profile and physical capacity and confirm its feasibility in older women.

METHODS

Inactive older women (60-75 years) were randomly assigned to 8 weeks of either HIIT (75 min/week; n=9) or MICT (150 min/week; n=9). Body composition, fasting metabolic profile, cardiovascular risk (Framingham score), and physical capacity (senior fitness test, VO2peak) were assessed before and after the intervention. Feasibility was evaluated with completion rate (training compliance; dropout rate) and affective response (Feeling scale; pre- and post-exercise).

RESULTS

Total cholesterol, non-HDL-C levels and the Framingham risk score decreased in both groups (all p≤0.03). Although VO2peak remained unchanged, the 6MWT distance increased (p<0.0001), irrespective of the group. Completion rate and affective responses were not different between groups (all p≥0.38).

CONCLUSION

A short-term HIIT program is feasible and provides as much benefits as MICT in older women.

Current trends in non-HDL cholesterol and LDL cholesterol levels in adults with atherosclerotic cardiovascular disease

BACKGROUND

Low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) are targets for prevention of atherosclerotic cardiovascular disease (ASCVD). The American Heart Association and American College of Cardiology recently modified recommendations for clinical management of cholesterol in secondary and primary prevention. Accordingly, the present article examines the need for cholesterol-lowering drugs in the U.S. population with ASCVD.

OBJECTIVE

This study examines trends in non-HDL-C and LDL-C levels in a free living population of ASCVD subjects between 1999 and 2016.

METHODS

National Health and Nutrition Examination Surveys database included 4920 adults with ASCVD aged 40 to 85 years. Complete data were available for 4226. Trend analysis of changes in lipids is shown in box plots.

RESULTS

Mean age was 67 years with 57% males. Over 17 years, LDL-C decreased significantly by 24% and non-HDL-C by 21%. Over the period of study, reported intake of cholesterol-lowering drugs rose from 37% in 1999-2000 to 69% in 2015 to 2016. Over this same period, serum triglycerides decreased by 29% (P < .001) and HDL-C rose by 6%.

CONCLUSIONS

The changes in LDL-C and non-HDL-C in patients with ASCVD over a 17-year period probably are related to increased treatment with statins. However, the changes are too small to be explained by widespread use of high-intensity statins, which is the current recommendation for patients with ASCVD. These findings pose a challenge for professional education to support implementation of current guidelines for cholesterol-lowering therapies.

Are non-high-density lipoprotein fractions associated with pediatric metabolic syndrome? The CASPIAN-V study

BACKGROUND

Non-high-density lipoprotein cholesterol (non-HDL-C) is considered as a valuable predictor for dyslipidemia and subclinical atherosclerosis which can be an appropriate index for identifying individuals with metabolic syndrome (MetS).

OBJECTIVE

To evaluate the association between non-HDL-C MetS and determine the optimal cut-points of non-HDL-C fractions for identifying MetS in Iranian children and adolescents.

METHODS

This nationwide study was conducted in the framework of the fifth survey of a national school-based surveillance program on children and adolescents aged 7-18 years. MetS was defined by the Adult Treatment Panel III (ATP III) criteria modified for the pediatric age group. The analysis of receiver operating characteristic (ROC) curve was applied to determine the optimal cut-points of non-HDL-C, difference between non-HDL-C and LDL-C (Diff-C) and triglycerides (TG) to HDL-C ratio (TG/HDL-C) for the prediction of MetS.

RESULTS

Overall, the study participants consisted of 3843 students (52.3% boys) with mean (±SD) age of 12.28 (3.1) years. The odds of high LDL-C, low HDL-C and MetS were increased in subjects with higher non-HDL-C, Diff-C and TG/HDL-C (P < 0.05). Non-HDL-C, Diff-C and TG/HDL-C cut-off points for predicting MetS were 120.5 mg/dl (sensitivity: 44%, specificity: 73%), 19.9 mg/dl (sensitivity: 85%, specificity: 75%) and 2.53 (sensitivity: 82%, specificity: 79%), respectively.

CONCLUSIONS

This study revealed a strong association between surrogates for serum lipid profile including non-HDL-C, TG/HDL-C and Diff-C and pediatric MetS. Our findings suggest that age- and gender-specific reference values of these markers were appropriate for both risk classification and long-term control of cardiovascular events in clinical assessments.

Fluvastatin for lowering lipids

BACKGROUND

Fluvastatin is thought to be the least potent statin on the market, however, the dose-related magnitude of effect of fluvastatin on blood lipids is not known.

OBJECTIVES

Primary objectiveTo quantify the effects of various doses of fluvastatin on blood total cholesterol, low-density lipoprotein (LDL cholesterol), high-density lipoprotein (HDL cholesterol), and triglycerides in participants with and without evidence of cardiovascular disease.Secondary objectivesTo quantify the variability of the effect of various doses of fluvastatin.To quantify withdrawals due to adverse effects (WDAEs) in randomised placebo-controlled trials.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to February 2017: the Cochrane Central Register of Controlled Trials (CENTRAL) (2017, Issue 1), MEDLINE (1946 to February Week 2 2017), MEDLINE In-Process, MEDLINE Epub Ahead of Print, Embase (1974 to February Week 2 2017), the World Health Organization International Clinical Trials Registry Platform, CDSR, DARE, Epistemonikos and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. No language restrictions were applied.

SELECTION CRITERIA

Randomised placebo-controlled and uncontrolled before and after trials evaluating the dose response of different fixed doses of fluvastatin on blood lipids over a duration of three to 12 weeks in participants of any age with and without evidence of cardiovascular disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility criteria for studies to be included, and extracted data. We entered data from placebo-controlled and uncontrolled before and after trials into Review Manager 5 as continuous and generic inverse variance data, respectively. WDAEs information was collected from the placebo-controlled trials. We assessed all trials using the 'Risk of bias' tool under the categories of sequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting, and other potential biases.

MAIN RESULTS

One-hundred and forty-five trials (36 placebo controlled and 109 before and after) evaluated the dose-related efficacy of fluvastatin in 18,846 participants. The participants were of any age with and without evidence of cardiovascular disease, and fluvastatin effects were studied within a treatment period of three to 12 weeks. Log dose-response data over doses of 2.5 mg to 80 mg revealed strong linear dose-related effects on blood total cholesterol and LDL cholesterol and a weak linear dose-related effect on blood triglycerides. There was no dose-related effect of fluvastatin on blood HDL cholesterol. Fluvastatin 10 mg/day to 80 mg/day reduced LDL cholesterol by 15% to 33%, total cholesterol by 11% to 25% and triglycerides by 3% to 17.5%. For every two-fold dose increase there was a 6.0% (95% CI 5.4 to 6.6) decrease in blood LDL cholesterol, a 4.2% (95% CI 3.7 to 4.8) decrease in blood total cholesterol and a 4.2% (95% CI 2.0 to 6.3) decrease in blood triglycerides. The quality of evidence for these effects was judged to be high. When compared to atorvastatin and rosuvastatin, fluvastatin was about 12-fold less potent than atorvastatin and 46-fold less potent than rosuvastatin at reducing LDL cholesterol. Very low quality of evidence showed no difference in WDAEs between fluvastatin and placebo in 16 of 36 of these short-term trials (risk ratio 1.52 (95% CI 0.94 to 2.45).

AUTHORS' CONCLUSIONS

Fluvastatin lowers blood total cholesterol, LDL cholesterol and triglyceride in a dose-dependent linear fashion. Based on the effect on LDL cholesterol, fluvastatin is 12-fold less potent than atorvastatin and 46-fold less potent than rosuvastatin. This review did not provide a good estimate of the incidence of harms associated with fluvastatin because of the short duration of the trials and the lack of reporting of adverse effects in 56% of the placebo-controlled trials.

Update on the laboratory investigation of dyslipidemias

The role of the clinical laboratory is evolving to provide more information to clinicians to assess cardiovascular disease (CVD) risk and target therapy more effectively. Current routine methods to measure LDL-cholesterol (LDL-C), the Friedewald calculation, ultracentrifugation, electrophoresis and homogeneous direct methods have established limitations. Studies suggest that LDL and HDL size or particle concentration are alternative methods to predict future CVD risk. At this time there is no consensus role for lipoprotein particle or subclasses in CVD risk assessment. LDL and HDL particle concentration are measured by several methods, namely gradient gel electrophoresis, ultracentrifugation-vertical auto profile, nuclear magnetic resonance and ion mobility. It has been suggested that HDL functional assays may be better predictors of CVD risk. To assess the issue of lipoprotein subclasses/particles and HDL function as potential CVD risk markers robust, simple, validated analytical methods are required. In patients with small dense LDL particles, even a perfect measure of LDL-C will not reflect LDL particle concentration. Non-HDL-C is an alternative measurement and includes VLDL and CM remnant cholesterol and LDL-C. However, apolipoprotein B measurement may more accurately reflect LDL particle numbers. Non-fasting lipid measurements have many practical advantages. Defining thresholds for treatment with new measurements of CVD risk remain a challenge. In families with genetic variants, ApoCIII and lipoprotein (a) may be additional risk factors. Recognition of familial causes of dyslipidemias and diagnosis in childhood will result in early treatment. This review discusses the limitations in current laboratory technologies to predict CVD risk and reviews the evidence for emergent approaches using newer biomarkers in clinical practice.

Association of low-density lipoprotein pattern with mortality after myocardial infarction: Insights from the TRIUMPH study

BACKGROUND

Studies of incident coronary heart disease risk within low-density lipoprotein (LDL) subclass (small, dense vs large, buoyant) have shown mixed results. No prospective cohort study has examined the association of small, dense, or large, buoyant LDL with mortality after myocardial infarction (MI).

OBJECTIVE

The objective of the study was to examine association of LDL pattern after MI and death.

METHODS

In 2476 patients hospitalized for MI, LDL pattern (A [large, buoyant], A/B [mixed], and B [small, dense]) was established by ultracentrifugation using Vertical Auto Profile. Using time-to-event analysis, we examined the association with 5-year mortality within LDL patterns, after adjusting for important patient and treatment characteristics. We additionally adjusted for LDL cholesterol (LDL-C) and triglyceride levels and used directly measured LDL-C and non-high-density lipoprotein cholesterol as exposures.

RESULTS

Patterns A, A/B, and B were present in 39%, 28%, and 33% of patients, respectively, with incident rates (per 1000 patient-years) of 50, 34, and 24 for all-cause and 24, 19, and 10 for CV mortality. The hazard ratios (95% confidence interval) with LDL patterns A/B and B compared with pattern A were 0.77 (0.61, 0.99) and 0.67 (0.51, 0.88) for all-cause, 0.94 (0.67, 1.33) and 0.69 (0.46, 1.03) for cardiovascular, and 0.64 (0.45, 0.91) and 0.65 (0.45, 0.93) for noncardiovascular mortalities, respectively. Results were similar when further adjusted for LDL-C and triglycerides, or with LDL-C and non-high-density lipoprotein cholesterol as exposures.

CONCLUSION

Compared with LDL pattern A, pattern B was significantly associated with reduced all-cause and non-CV mortalities with a trend for lower CV mortality after MI, independent of LDL-C and triglycerides.

Effects of extended-release niacin/laropiprant on correlations between apolipoprotein B, LDL-cholesterol and non-HDL-cholesterol in patients with type 2 diabetes

BACKGROUND

LDL-C, non-HDL-C and ApoB levels are inter-correlated and all predict risk of atherosclerotic cardiovascular disease (ASCVD) in patients with type 2 diabetes mellitus (T2DM) and/or high TG. These levels are lowered by extended-release niacin (ERN), and changes in the ratios of these levels may affect ASCVD risk. This analysis examined the effects of extended-release niacin/laropiprant (ERN/LRPT) on the relationships between apoB:LDL-C and apoB:non-HDL-C in patients with T2DM.

METHODS

T2DM patients (n = 796) had LDL-C ≥1.55 and <2.97 mmol/L and TG <5.65 mmol/L following a 4-week, lipid-modifying run-in (~78 % taking statins). ApoB:LDL-C and apoB:non-HDL-C correlations were assessed after randomized (4:3), double-blind ERN/LRPT or placebo for 12 weeks. Pearson correlation coefficients between apoB:LDL-C and apoB:non-HDL-C were computed and simple linear regression models were fitted for apoB:LDL-C and apoB:non-HDL-C at baseline and Week 12, and the correlations between measured apoB and measured vs predicted values of LDL-C and non-HDL-C were studied.

RESULTS

LDL-C and especially non-HDL-C were well correlated with apoB at baseline, and treatment with ERN/LRPT increased these correlations, especially between LDL-C and apoB. Despite the tighter correlations, many patients who achieved non-HDL-C goal, and especially LDL-C goal, remained above apoB goal. There was a trend towards greater increases in these correlations in the higher TG subgroup, non-significant possibly due to the small number of subjects.

CONCLUSIONS

ERN/LRPT treatment increased association of apoB with LDL-C and non-HDL-C in patients with T2DM. Lowering LDL-C, non-HDL-C and apoB with niacin has the potential to reduce coronary risk in patients with T2DM.

High triglyceride levels alter the correlation of apolipoprotein B with low- and non-high-density lipoprotein cholesterol mostly in individuals with diabetes or metabolic syndrome

OBJECTIVE

To assess the correlation of Apolipoprotein B (Apo-B) with low-density (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C) in untreated individuals attending a lipid clinic.

METHODS

This was a retrospective study conducted in Greece and including 1000 dyslipidemic subjects. We included individuals not taking lipid-lowering therapy at baseline visit and divided them in 2 groups: subjects diagnosed with diabetes or fulfilling the criteria of metabolic syndrome (MetS) and hyperlipidemic subjects without diabetes or MetS. The correlations (r(2)) of Apo-B with LDL-C and non-HDL-C were assessed in these 2 groups. Further analyses were performed according to the baseline triglyceride (TG) levels (<and ≥200 mg/dL).

RESULTS

From 821 eligible subjects, 51% were diagnosed with diabetes or MetS. The correlations between Apo-B and LDL-C or non-HDL-C were similar for the individuals with TG < 200 mg/dL. Specifically, Apo-B was significantly correlated with LDL-C (r(2) = 0.755, p < 0.01, for those with diabetes or MetS; r(2) = 0.848, p < 0.01, for non-diabetic and no MetS hyperlipidemic subjects). The corresponding correlations between Apo-B and non-HDL-C for the 2 groups were 0.743 and 0.838, respectively (p < 0.01). Although these correlations remained significant for the individuals with high TG levels (≥200 mg/dL), the correlation factor was markedly decreased mostly in those with diabetes or MetS (r(2) = 0.600, p < 0.01, for the correlation between Apo-B and LDL-C; r(2) = 0.604, p < 0.01, for the correlation between Apo-B and non-HDL-C); in contrast, the corresponding correlations were stronger in the non-diabetic and no MetS hyperlipidemic individuals (r(2) = 0.710 and 0.714, respectively, p < 0.01).

CONCLUSION

Apo-B correlation with both LDL-C and non-HDL-C is reduced in individuals with high TG levels and in particular for those with diabetes or MetS.

Lipid-lowering efficacy of atorvastatin

BACKGROUND

This represents the first update of this review, which was published in 2012. Atorvastatin is one of the most widely prescribed drugs and the most widely prescribed statin in the world. It is therefore important to know the dose-related magnitude of effect of atorvastatin on blood lipids.

OBJECTIVES

Primary objective To quantify the effects of various doses of atorvastatin on serum total cholesterol, low-density lipoprotein (LDL)-cholesterol, high-density lipoprotein (HDL)-cholesterol and triglycerides in individuals with and without evidence of cardiovascular disease. The primary focus of this review was determination of the mean per cent change from baseline of LDL-cholesterol. Secondary objectives • To quantify the variability of effects of various doses of atorvastatin.• To quantify withdrawals due to adverse effects (WDAEs) in placebo-controlled randomised controlled trials (RCTs).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 11, 2013), MEDLINE (1966 to December Week 2 2013), EMBASE (1980 to December Week 2 2013), Web of Science (1899 to December Week 2 2013) and BIOSIS Previews (1969 to December Week 2 2013). We applied no language restrictions.

SELECTION CRITERIA

Randomised controlled and uncontrolled before-and-after trials evaluating the dose response of different fixed doses of atorvastatin on blood lipids over a duration of three to 12 weeks.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility criteria for studies to be included and extracted data. We collected information on withdrawals due to adverse effects from placebo-controlled trials.

MAIN RESULTS

In this update, we found an additional 42 trials and added them to the original 254 studies. The update consists of 296 trials that evaluated dose-related efficacy of atorvastatin in 38,817 participants. Included are 242 before-and-after trials and 54 placebo-controlled RCTs. Log dose-response data from both trial designs revealed linear dose-related effects on blood total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides. The Summary of findings table 1 documents the effect of atorvastatin on LDL-cholesterol over the dose range of 10 to 80 mg/d, which is the range for which this systematic review acquired the greatest quantity of data. Over this range, blood LDL-cholesterol is decreased by 37.1% to 51.7% (Summary of findings table 1). The slope of dose-related effects on cholesterol and LDL-cholesterol was similar for atorvastatin and rosuvastatin, but rosuvastatin is about three-fold more potent. Subgroup analyses suggested that the atorvastatin effect was greater in females than in males and was greater in non-familial than in familial hypercholesterolaemia. Risk of bias for the outcome of withdrawals due to adverse effects (WDAEs) was high, but the mostly unclear risk of bias was judged unlikely to affect lipid measurements. Withdrawals due to adverse effects were not statistically significantly different between atorvastatin and placebo groups in these short-term trials (risk ratio 0.98, 95% confidence interval 0.68 to 1.40).

AUTHORS' CONCLUSIONS

This update resulted in no change to the main conclusions of the review but significantly increases the strength of the evidence. Studies show that atorvastatin decreases blood total cholesterol and LDL-cholesterol in a linear dose-related manner over the commonly prescribed dose range. New findings include that atorvastatin is more than three-fold less potent than rosuvastatin, and that the cholesterol-lowering effects of atorvastatin are greater in females than in males and greater in non-familial than in familial hypercholesterolaemia. This review update does not provide a good estimate of the incidence of harms associated with atorvastatin because included trials were of short duration and adverse effects were not reported in 37% of placebo-controlled trials.

Therapeutic lipid target achievements among high and highest risk patients: results from the CEPHEUS study in the Arabian Gulf

OBJECTIVE

To determine lipid target achievements of low-density lipoprotein cholesterol (LDL-C), non-high density lipoprotein cholesterol (non-HDL-C) and apolipoprotein B (apo B) in the Centralized Pan-Middle East Survey on the undertreatment of hypercholesterolemia (CEPHEUS) in Arabian Gulf States patients with high and highest risk according to the joint Consensus Statement of the American Diabetes Association (ADA) and American College of Cardiology Foundation (ACC).

METHODS

CEPHEUS was conducted in patients (≥ 18 years of age) in six Middle Eastern countries between November 2009 and July 2010 on lipid lowering drugs (LLDs). Serum samples collected included total cholesterol (TC), LDL-C, HDL-C, triglycerides (TGs), apo B, and apolipoprotein A1 (apo A1).

RESULTS

The overall mean age of the cohort (n = 5275) was 56 ± 13 years, 58% (n = 3060) were male and 69% (n = 3635) were highest risk. LDL-C target was achieved in 25%, non-HDL-C in 36% and apo B in 38% of patients in the highest risk cohort compared with LDL-C 46%, non-HDL-C 58% and apo B 51% in the high risk group. In patients with TGs ≥ 2.2 mmol/L, LDL-C target was achieved in 16% and apo B in 15% of patients in the highest risk group compared with LDL-C 32% and apo B 22% in the high risk cohort.

CONCLUSION

Despite being on LLDs, a large proportion of high and highest risk patients in the Arabian Gulf are not at recommended lipid targets and remain at a substantial residual risk for cardiovascular diseases. Apo B may be used as an additional target in patients with triglycerides ≥ 2.2 mmol/L. The findings should be interpreted in light of the study's limitations.

New therapies targeting apoB metabolism for high-risk patients with inherited dyslipidaemias: what can the clinician expect?

Apolipoprotein B (apoB) has a key role in the assembly and secretion of very low-density lipoprotein (VLDL) from the liver. Plasma apoB concentration affects the number of circulating atherogenic particles, and serves as an independent predictor of the risk of atherosclerotic cardiovascular disease. While statins are the most potent apoB-lowering agents currently prescribed, their efficacy in achieving therapeutic targets for low-density lipoprotein cholesterol (LDL-C) in high-risk patients, such as those with familial hypercholesterolaemia (FH), is limited. Resistance and intolerance to statins also occurs in a significant number of patients, necessitating new types of lipid-lowering therapies. Monoclonal antibodies against proprotein convertase subtilisin/kexin type 9 (PCSK9; AMG 145 and REGN727), a sequence-specific antisense oligonucleotide against apoB mRNA (mipomersen) and a synthetic inhibitor of microsomal triglyceride transfer protein (MTTP; lomitapide) have been tested in phase III clinical trials, particularly in patients with FH. The trials demonstrated the efficacy of these agents in lowering apoB, LDL-C, non-high-density lipoprotein cholesterol and lipoprotein(a) by 32-55 %, 37-66 %, 38-61 % and 22-50 % (AMG 145), 21-68 %, 29-72 %, 16-60 % and 8-36 % (REGN727), 16-71 %, 15-71 %, 12-66 % and 23-49 % (mipomersen) and 24-55 %, 25-51 %, 27-50 % and 15-19 % (lomitapide), respectively. Monoclonal antibodies against PCSK9 have an excellent safety profile and may be indicated not only in heterozygous FH, but also in statin-intolerant patients and those with other inherited dyslipidemias, such as familial combined hyperlipidaemia and familial elevation in Lp(a). Mipomersen and lomitapide increase hepatic fat content and are at present indicated for treating adult patients with homozygous FH alone.

Effects of extended-release niacin/laropiprant, simvastatin, and the combination on correlations between apolipoprotein B, LDL cholesterol, and non-HDL cholesterol in patients with dyslipidemia

BACKGROUND

Statins modify correlations between apolipoprotein B (apoB) and low-density lipoprotein cholesterol (LDL-C) and apoB and non-high-density lipoprotein cholesterol (non-HDL-C); however, it is not known whether niacin-based therapies have similar effects.

OBJECTIVE

To evaluate the effects of extended-release niacin (ERN)/laropiprant (LRPT), simvastatin (SIMVA), and ERN/LRPT + SIMVA (pooled ERN/LRPT + SIMVA) on apoB:LDL-C and apoB:non-HDL-C correlations in dyslipidemic patients.

METHODS

This post-hoc analysis of a 12-week study evaluated the apoB:LDL-C and apoB:non-HDL-C correlations in dyslipidemic patients randomized equally to double-blind ERN/LRPT 1 g/20 mg, SIMVA 10, 20, or 40 mg, or ERN/LRPT 1 g/20 mg + SIMVA (10, 20, or 40 mg) once daily for 4 weeks. At week 5, doses were doubled in all groups except SIMVA 40 mg (unchanged) and ERN/LRPT 1 g/20 mg + SIMVA 40 mg (switched to ERN/LRPT 2 g/40 mg + SIMVA 40 mg). Simple linear regression analyses were used to calculate LDL-C and non-HDL-C levels corresponding to known apoB baseline values (ie, in untreated patients) and following treatment.

RESULTS

The apoB:LDL-C and apoB:non-HDL-C correlations were higher and the predicted LDL-C and non-HDL-C levels for a known apoB value were considerably lower following treatment with ERN/LRPT, SIMVA and ERN/LRPT + SIMVA compared with untreated patients at baseline.

CONCLUSION

Greater dissociation of apoB, LDL-C, and non-HDL-C targets occur following treatment with ERN/LRPT, SIMVA, and ERN/LRPT + SIMVA in patients with dyslipidemia. The achievement of more aggressive LDL-C and non-HDL-C goals in patients receiving lipid-modifying therapy may further reduce coronary risk by normalizing apoB-containing atherogenic lipoproteins.

Metabolic effects of fluvastatin extended release 80 mg and atorvastatin 20 mg in patients with type 2 diabetes mellitus and low serum high-density lipoprotein cholesterol levels: a 4-month, prospective, open-label, randomized, blinded-end point (probe) trial

BACKGROUND

Diabetic dyslipidemia is characterized by greater triglyceridation of all lipoproteins and low levels of plasma high-density lipoprotein cholesterol (HDL-C). In this condition, the serum level of low-density lipoprotein cholesterol (LDL-C) is only slightly elevated. The central role of decreased serum HDL-C level in diabetic cardiovascular disease has prompted the establishment of a target of ≥50 mg/dL in patients with diabetes mellitus (DM).

OBJECTIVE

The aim of the study was to assess the effects of once-daily administration of fluvastatin extended release (XL) 80 mg or atorvastatin 20 mg on serum HDL-C levels in patients with type 2 DM and low levels of serum HDL-C.

METHODS

This 4-month, prospective, open-label, randomized, blinded-end point (PROBE) trial was conducted at Endocrinology and Diabetology Service, L. Sacco-Polo University Hospital (Milan, Italy). Patients aged 45 to 71 years with type 2 DM receiving standard oral antidiabetic therapy, with serum HDL-C levels <50 mg/dL, and with moderately high serum levels of LDL-C and triglycerides (TG) were enrolled. After 1 month of lifestyle modification and dietary intervention, patients who were still showing a decreased HDL-C level were randomized, using a 1:1 ratio, to receive fluvastatin XL 80-mg tablets or atorvastatin 20-mg tablets, for 3 months. Lipoprotein metabolism was assessed by measuring serum levels of LDL-C, HDL-C, TG, apolipoprotein (apo) A-I (the lipoprotein that carries HDL), and apo B (the lipoprotein that binds very low-density lipoprotein cholesterol, intermediate-density lipoprotein, and LDL on a molar basis). Patients were assessed every 2 weeks for treatment compliance and subjective adverse events. Serum creatine phosphokinase and liver enzymes were assessed before the run-in period, at the start of the trial, and at 1 and 3 months during the study.

RESULTS

One hundred patients were enrolled (50 patients per treatment group; fluvastatin XL group: 33 men, 17 women; mean [SD] age, 58 [12] years; atorvastatin group: 39 men, 11 women; mean [SD] age, 59 [11] years). In the fluvastatin group after 3 months of treatment, mean (SD) LDL-C decreased from 149 (33) to 95 (25) mg/dL (36%; P < 0.01), TG decreased from 437 (287) to 261 (164) mg/dL (40%; P < 0.01), and HDL-C increased from 41 (7) to 46 (10) mg/dL (12%; P < 0.05). In addition, apo A-I increased from 118 (18) to 124 (15) mg/dL (5%; P < 0.05) and apo B decreased from 139 (27) to 97 (19) mg/dL (30%; P < 0.05). In the atorvastatin group, LDL-C decreased from 141 (25) to 84 (23) mg/dL (40%; P < 0.01) and TG decreased from 411 (271) to 221 (87) mg/dL (46%; P < 0.01). Neither HDL-C (41 [7] vs 40 [6] mg/dL; 2%) nor apo A-I (117 [19] vs 114 [19] mg/dL; 3%) changed significantly. However, apo B decreased significantly, from 131 (20) to 92 (17) mg/dL (30%; P < 0.05). Mean changes in HDL-C (+5 [8] vs -1 [2] mg/dL; P < 0.01) and apo A-I (+6 [18] mg/dL vs -3 [21] mg/dL; P < 0.01) were significantly greater in the fluvastatin group than in the atorvastatin group, respectively. However, the decreases in LDL-C (54 [31] vs 57 [32] mg/ dL), TG (177 [219] vs 190 [65] mg/dL), and apo B (42 [26] vs 39 [14] mg/dL) were not significantly different between the fluvastatin and atorvastatin groups, respectively. No severe adverse events were reported.

CONCLUSIONS

Fluvastatin XL 80 mg and atorvastatin 20 mg achieved mean serum LDL-C (≤ 100 mg/dL) and apo B target levels (≤ 100 mg/dL) in the majority of this population of patients with type 2 DM, but mean serum HDL-C level was increased significantly only with fluvastatin-16 patients (32%) in the fluvastatin group compared with none in the atorvastatin group achieved HDL-C levels ≥50 mg/dL. The increase in HDL-C in the fluvastatin-treated patients was associated with an increase in apo A-I, suggesting a potential pleiotropic and selective effect in patients with low HDL-C levels.

Association between nontraditional risk factors and metabolic syndrome in indigenous Argentinean schoolchildren

BACKGROUND

Whether apolipoproteins (Apos) are better cardiovascular disease (CVD) markers than metabolic syndrome (MS) is widely debated. Measurement of Apo B is standardized, simple, and inexpensive and does not require fasting. The aim of this study was to compare the ability of nontraditional CVD markers such as Apo B, Apo B/Apo A, non-high-density lipoprotein cholesterol (HDL-C), vitamin D, and homeostasis model assessment of insulin resistance (HOMA-IR) to identify children with MS.

SUBJECTS AND METHODS

A cross-sectional study of 355 Argentinean Koya schoolchildren (166 boys) 9.6±2.3 years old was performed in November 2011. Anthropometric measures, blood pressure, Tanner stages, and serum levels of glucose, lipids, insulin, Apo A, Apo B, and vitamin D were measured.

RESULTS

The prevalence of overweight/obesity was 10.7% (n=38), and that of underweight was 14.6% (n=52) using Centers for Disease Control and Prevention criteria. The prevalence of central obesity was 10.9% (38/355), high triglycerides was 11.1% (39/355), low HDL-C was 44.9% (158/355), hypertension was 12.8% (45/355), hyperglycemia was 0.3% (1/355), and MS was 4.2% (15/355). Several multiple logistic regression analyses showed that MS was significantly associated with HOMA-IR (odds ratio [OR], 3.6 [95% confidence interval (CI) 1.51-8.52]), non-HDL-C (OR, 1.03 [95% CI 1.007-1.049]), Apo B (OR, 1.06 [95% CI 1.03-1.09]), and Apo B/Apo A (OR, 78.3 [95% CI 3.67-1,674.4]) adjusted for age and gender. Furthermore, the areas under the receiver operator characteristic curves were as follows: Apo B, 0.77 (95% CI 0.63-0.90); Apo B/Apo A, 0.76 (95% CI 0.63-0.88); non-HDL-C, 0.72 (95% CI 0.57-0.85); and HOMA-IR, 0.69 (95% CI 0.49-0.90). These values indicate that these variables were acceptable predictors for MS.

CONCLUSIONS

This is the first study of nontraditional markers in South American Indian children. MS was associated with multiple nontraditional markers of future CVD risk such as non-HDL-C, Apo B, and Apo B/Apo A. However, Apo B was the best predictor for MS, suggesting that it could be used as a risk marker of future CVD in this community.

Effects of ezetimibe, simvastatin and ezetimibe/simvastatin on correlations between apolipoprotein B, LDL cholesterol and non-HDL cholesterol in patients with primary hypercholesterolemia

BACKGROUND/SYNOPSIS

Apolipoprotein (apo) B is highly predictive of coronary risk, especially in patients with high triglycerides (TG). This post hoc analysis evaluated the effects of lipid-lowering therapy on correlations between apoB and low-density lipoprotein cholesterol (apoB:LDL-C) and non-high-density lipoprotein cholesterol (apoB:non-HDL-C) in patients with TG< and ≥ 200 mg/dL.

METHODS

This analysis used data from 3 randomized clinical trials in patients with primary hypercholesterolemia receiving placebo, ezetimibe (EZE), simvastatin (SIMVA) or EZE/SIMVA for 12 weeks. Simple linear regression analyses predicted LDL-C and non-HDL-C levels corresponding to apoB values (80 mg/dL) at baseline and Week 12.

RESULTS

ApoB correlated with LDL-C (r ≥ 0.76) and non-HDL-C (r ≥ 0.86) at baseline. The correlations were strengthened with SIMVA and EZE/SIMVA at Week 12 (r ≥ 0.88 for LDL-C and r ≥ 0.94 for non-HDL-C). The predicted LDL-C and non-HDL-C values were lower following treatment with SIMVA or EZE/SIMVA than for placebo and EZE. For SIMVA and EZE/SIMVA, the predicted LDL-C and non-HDL-C values were closer to more aggressive LDL-C and non-HDL-C levels (i.e., 70 and 100 mg/dL, respectively). The apoB:LDL-C and apoB:non-HDL-C correlations were weaker and the predicted LDL-C values were generally lower in high TG patients than in low TG patients both at baseline and Week 12. In contrast, the predicted non-HDL-C values were generally higher in high versus low TG patients at baseline but less so at Week 12.

CONCLUSION

After treatment with EZE, SIMVA, or EZE/SIMVA, a given apoB value corresponds to lower LDL-C and non-HDL-C levels than those obtained from untreated patients.

Comparison of therapeutic lipid target achievements among high-risk patients in Oman

We compared therapeutic lipid target achievements among patients with diabetes or coronary heart disease (CHD) in Oman. A retrospective chart review of 94 patients was conducted at an outpatient clinic in Sultan Qaboos University Hospital, Muscat, Oman. The variables included low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and apolipoprotein B (apo B). The overall mean age of the cohort was 59 ± 12 years, 54% were male, 66% were diabetic, 48% hypertensive, 45% had CHD, 94% were on simvastatin, 4% were on fenofibrate, and 2% were on both simvastatin and fenofibrate. Lipid goal attainments of calculated LDL-C (<2.6 mmol/L), apo B (<0.9 g/L), and non-HDL-C (<3.36 mmol/L) were reached in 52%, 39%, and 53% of the patients, respectively. A significant proportion of high-risk patients treated with lipid-lowering agents reach LDL-C but not the apo B treatment targets, suggesting that the use of apo B target values should also be considered.

Lipid lowering efficacy of atorvastatin

BACKGROUND

Atorvastatin is one of the most widely prescribed drugs and the most widely prescribed statin in the world. It is therefore important to know the dose-related magnitude of effect of atorvastatin on blood lipids.

OBJECTIVES

To quantify the dose-related effects of atorvastatin on blood lipids and withdrawals due to adverse effects (WDAE).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library Issue 4, 2011, MEDLINE (1966 to November 2011), EMBASE (1980 to November 2011), ISI Web of Science (1899 to November 2011) and BIOSIS Previews (1969 to November 2011). No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled and uncontrolled before-and-after trials evaluating the dose response of different fixed doses of atorvastatin on blood lipids over a duration of 3 to 12 weeks.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. WDAE information was collected from the placebo-controlled trials.

MAIN RESULTS

Two hundred fifty-four trials evaluated the dose-related efficacy of atorvastatin in 33,505 participants. Log dose-response data revealed linear dose-related effects on blood total cholesterol, low-density lipoprotein (LDL)-cholesterol and triglycerides. Combining all the trials using the generic inverse variance fixed-effect model for doses of 10 to 80 mg/day resulted in decreases of 36% to 53% for LDL-cholesterol. There was no significant dose-related effects of atorvastatin on blood high-density lipoprotein (HDL)-cholesterol. WDAE were not statistically different between atorvastatin and placebo for these short-term trials (risk ratio 0.99; 95% confidence interval 0.68 to 1.45).

AUTHORS' CONCLUSIONS

Blood total cholesterol, LDL-cholesterol and triglyceride lowering effect of atorvastatin was dependent on dose. Log dose-response data was linear over the commonly prescribed dose range. Manufacturer-recommended atorvastatin doses of 10 to 80 mg/day resulted in 36% to 53% decreases of LDL-cholesterol. The review did not provide a good estimate of the incidence of harms associated with atorvastatin because of the short duration of the trials and the lack of reporting of adverse effects in 37% of the placebo-controlled trials.

The effects of resistance training on ApoB/ApoA-I ratio, Lp(a) and inflammatory markers in patients with type 2 diabetes

The purpose of this study was to investigate the effects of resistance training (RT) on novel cardiovascular risk factors in patients with type 2 diabetes mellitus (T2DM). We enrolled 52 overweight/obese, type 2 diabetic patients, with inadequate glycemic control (HbA1c > 6.5 %), but without overt diabetic vascular complications. Participants were randomly assigned into two equivalent groups (n = 26): (1) Resistance exercise group: subjects underwent a supervised RT program (3-times/week, 60 min/session, 2-3 sets of 8 machine-weight exercises, 60-80 % of one-repetition maximum). (2) Control group (CG): at study entrance, they received a structured exercise counseling to increase daily physical activity. Clinical parameters, cardiorespiratory capacity, glycemic and lipid profile, apolipoprotein A-I (ApoA-I), apolipoprotein B (ApoB), Lipoprotein(a) [Lp(a)], insulin resistance (HOMA-IR), high-sensitivity CRP (hsCRP), fibrinogen were measured before and after 3 months. RT significantly reduced glycemic indexes, insulin resistance and systolic blood pressure, compared to CG (p < 0.05). Moreover, exercise-treated patients conferred a remarkable downregulation in ApoB levels (from 135.92 ± 30.97 mg/dL to 85.9 ± 26.46 mg/dL, p < 0.001) as compared to CG (from 126.33 ± 36.59 mg/dL to 116.23 ± 27.52 mg/dL, p = 0.872) (p < 0.001). Similarly, ApoB/ApoA-I ratio was considerably decreased in REG rather than CG (-0.32 ± 0.09 vs 0.02 ± 0.01, p < 0.001). Notably, ApoA-I, Lp(a), hsCRP, fibrinogen, the rest of lipid parameters, body weight and exercise capacity remained unaltered in both groups (p > 0.05). Among variables, HOMA-IR reduction was found to be an independent predictor of changes in ApoB/ApoA-I ratio (R (2) = 0.406, p = 0.041) in REG. Long-term RT ameliorated glycemic control, insulin sensitivity and ApoB/ApoA-I ratio in individuals with T2DM. Although we did not observe significant benefits in the rest of cardiovascular risk factors, our results indicate a merely beneficial impact of RT.

Assessing the clinical utility of biomarkers in medicine

Biomarkers in medicine have gained immense scientific and clinical interest in recent years. Biomarkers are potentially useful in the contexts of primary, secondary and tertiary prevention. Some of the characteristics of an ideal biomarker include that they are safe and easy to measure, are associated with acceptable costs (including those of the follow-up tests), and there is scientific evidence to suggest that biomarker use/modification influences disease outcomes. Additionally, variation in biomarker levels with gender and ethnicity should be elucidated, and the biomarker should have 'good performance characteristics' (i.e., sensitivity, specificity, positive- and negative-predictive values and positive- and negative-likelihood ratios). Risk prediction scores can combine information from several different biomarkers in order to estimate an individual's risk of developing an outcome, such as disease or death. Three commonly employed methods to test if a biomarker will add to traditional risk prediction models are model discrimination, model calibration and risk reclassification. 'Multimarker' strategies serve to integrate information from multiple biomarkers into risk prediction but may be limited by the presence of highly correlated biomarkers, economic costs and selection bias of biomarker candidates in a particular study sample. In the future, integration of biomarkers identified using emerging technologies from the 'omics fields (including genomics, proteomics, metabolomics, lipomics, ribomics and pharmacogenomics) may be useful for the 'personalization' of treatment/disease prevention.

Relative Efficacy of Antilipemic Agents in Non–High-Density Lipoprotein Cholesterol Reduction

The investigators sought to summarize the percentage reduction in non–high-density lipoprotein cholesterol (non-HDL-C) achieved with various antilipemic regimens and to determine whether certain antilipemic regimens have been proven more effective in lowering non-HDL-C. A search of MEDLINE, International Pharmaceutical Abstracts, and Iowa Drug Information Service Database from 1970 to May 2011 was performed. Criteria were used to exclude studies not published in English, studies with methodology limitations, and studies with variables that may affect efficacy beyond the antilipemic agent administered. Only randomized, controlled trials comparing medications approved by the Food and Drug Administration were reviewed to determine whether significant differences in percentage reduction in non-HDL-C had been observed between different medication regimens. A total of 51 trials reported data that could be used to determine the range of percentage reduction in non-HDL-C achieved by select antilipemic regimens. Of these 51 trials, 38 provided head-to-head comparisons of antilipemic regimens. Rosuvastatin and atorvastatin are the most potent 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) in lowering non-HDL-C. Adding ezetimibe, fibric acid derivatives, and omega-3 fatty acids to antilipemic monotherapy may result in further reduction in non-HDL-C. Subjects with certain characteristics (eg, nonwhite) were not prevalent in these studies.

Non-high-density lipoprotein cholesterol reporting and goal attainment in primary care

BACKGROUND

The Adult Treatment Panel III guidelines established non-high-density lipoprotein cholesterol (non-HDL-C) as a secondary treatment target. However, non-HDL-C levels are not reported on standard lipid panels by many hospital-based and/or commercial biochemical laboratories.

OBJECTIVE

We determined whether reporting non-HDL-C was associated with improved non-HDL-C goal attainment.

METHODS

We identified patients with cardiovascular disease (CVD) and/or diabetes receiving care within the Veterans Health Administration. We matched a facility that reported non-HDL-C levels on lipid panels (3994 CVD and 5108 diabetes patients) to a facility with similar size, patient complexity, and academic mission that did not report non-HDL-C (4269 CVD and 6591 diabetes patients). We performed patient-level analysis to assess differences in non-HDL-C from baseline to the most recent lipid panel at these facilities.

RESULTS

Baseline non-HDL-C levels for CVD patients were 114 mg/dL and 107 mg/dL at the reporting and nonreporting facilities, respectively. At 2.3-year follow-up, non-HDL-C levels decreased at both facilities but by a greater amount at the reporting facility (-11 mg/dL vs -3 mg/dL at the nonreporting facility, P < .001). Results remained significant (P < .001) after we adjusted for patient's age, race, gender, illness burden, history of diabetes, hypertension, medication adherence, statin use, number of lipid panels, and number of primary care visits between baseline and follow-up. Reductions were greater among CVD patients with triglycerides ≥200 mg/dL (-25 mg/dL vs -16 mg/dL at the respective facilities, P = .004). Results were similar in diabetes patients. Reporting was also associated with greater proportions of patients meeting non-HDL-C treatment goal of <130 mg/dL.

CONCLUSION

Non-HDL-C reporting could improve non-HDL-C goal attainment.

Attainment of goal/desirable lipid levels in patients with mixed dyslipidemia after 12 weeks of treatment with fenofibric acid and rosuvastatin combination therapy: a pooled analysis of controlled studies

BACKGROUND

Goal/desirable lipid levels are underachieved in patients with mixed dyslipidemia. These patients may have substantial residual risk of cardiovascular disease even while receiving optimal LDL-C-lowering therapy and may require additional therapy to improve multiple lipid/lipoprotein levels.

OBJECTIVE

To evaluate attainment of goal/desirable levels of lipids/lipoproteins after 12-week treatment with combination rosuvastatin + fenofibric acid versus rosuvastatin monotherapy.

METHODS

This was a post hoc analysis of patients with mixed dyslipidemia who enrolled in one of two randomized controlled trials, and were treated (N = 2066) with rosuvastatin (5, 10, or 20 mg), fenofibric acid 135 mg, or rosuvastatin + fenofibric acid for 12 weeks. Data were pooled across doses of rosuvastatin as monotherapy and combination therapy.

RESULTS

Compared with rosuvastatin monotherapy, combination therapy had comparable effects in achieving risk-stratified LDL-C goals; however, measures of total atherogenic burden were improved because significantly greater percentages of patients attained non-HDL-C goal in high- (62.9% vs 50.4%, P = .006) and moderate-risk groups (87.6% vs 80.4%, P = .016) and apolipoprotein B (ApoB) <90 mg/dL in high-risk group (59.8% vs 43.8%, P < .001). In the overall population, more patients treated with the combination therapy achieved desirable levels of HDL-C >40/50 mg/dL in men/women (P < .001), triglycerides <150 mg/dL (P < .001), and ApoB <90 mg/dL (P < .001), compared with rosuvastatin monotherapy. Furthermore, combination therapy resulted in significantly greater percentages of patients achieving simultaneous specified levels of LDL-C + non-HDL-C (P < .015); LDL-C + HDL-C + TG (P < .001); and LDL-C + HDL-C + triglycerides + non-HDL-C + ApoB (P < .001), compared with rosuvastatin monotherapy.

CONCLUSION

Rosuvastatin + fenofibric acid may be more efficacious than rosuvastatin alone in patients with mixed dyslipidemia.

Clinical Impact of Non-High Density Lipoprotein-Cholesterol and Apolipoprotein B on Clinical Outcomes in Metabolic Syndrome Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Background and Objectives

Subjects and Methods

Results

Conclusion

Non-high-density lipoprotein cholesterol is a practical predictor of long-term cardiac death after coronary artery bypass grafting

BACKGROUND

Recent studies have demonstrated that non-high-density lipoprotein cholesterol (non-HDL-C) can predict the risk of cardiovascular events among general population without coronary heart disease (CHD). However, few studies have investigated the predictive value of non-HDL-C for long-term prognosis in patients with CHD. The purpose of this study was to investigate whether non-HDL-C can predict long-term cardiovascular events in patients with CHD who underwent coronary artery bypass grafting (CABG).

METHODS

We enrolled 1074 consecutive patients who underwent CABG at Juntendo University Hospital between 1984 and 1994, and obtained mortality data through 2000. We divided the patients into 2 groups by the median non-HDL-C level at baseline (180 mg/dL) and used Kaplan-Meier method with log-rank test for survival analyses. Cox proportional-hazard regression model was used to calculate the relative risk (RR) of cardiac death.

RESULTS

The mean follow-up period was 10.6±3.5 years. The survival rate of cardiac death was significantly lower in the high non-HDL-C group than that in the low non-HDL-C group (log-rank test; p=0.006). Furthermore, in proportional regression analysis adjusted for conventional coronary risk factors, metabolic syndrome, statin treatment, and use of artery bypass graft, the increased levels of non-HDL-C were significant and independent predictor of cardiac death beyond other lipid parameters (RR1.22; by 10 mg/dL non-HDL-C increasing, 95% confidence interval 1.03-1.44; p<0.05).

CONCLUSIONS

The increased levels of non-HDL-C were significantly associated with an increased risk of cardiac death. Baseline non-HDL-C levels may be a practical predictor of long-term cardiac death in patients with CHD after CABG.

Non-high-density lipoprotein cholesterol versus apolipoprotein B in cardiovascular risk stratification: do the math

With the emergence of new lipid risk markers and a growing cardiometabolic risk burden in the United States, there is a need to better integrate residual risk into cardiovascular disease (CVD) risk stratification. In anticipation of the Adult Treatment Panel IV (ATP IV) guidelines from the National Cholesterol Education Program (NCEP), there exists controversy regarding the comparative performance of the 2 foremost markers, apolipoprotein B (apoB) and non-high-density lipoprotein cholesterol (non-HDL-C), as they relate to the current standard of risk assessment and treatment: low-density lipoprotein cholesterol (LDL-C). Although some emerging markers may demonstrate better performance compared with LDL-C, certain fundamental characteristics intrinsic to a beneficial biomarker must be met prior to routine use. Collectively, studies have found that non-HDL-C and apoB perform better than LDL-C in CVD risk prediction, both on- and off-treatment, as well as in subclinical CVD risk prediction. The performance of non-HDL-C compared with apoB, however, has been a point of ongoing debate. Although both offer the practical benefits of accuracy independent of triglyceride level and prandial state, non-HDL-C proves to be the better marker of choice at this time, given established cutpoints with safe and achievable goals, no additional cost, and quick time to result with an easy mathematical calculation. The purpose of this review is to assess the performance of these parameters in this context and to discuss the considerations of implementation into clinical practice.

Comparisons of apolipoprotein B levels estimated by immunoassay, nuclear magnetic resonance, vertical auto profile, and non-high-density lipoprotein cholesterol in subjects with hypertriglyceridemia (SAFARI Trial)

Low-density lipoprotein (LDL) cholesterol and triglyceride-rich lipoproteins constitute non-high-density lipoprotein (non-HDL) cholesterol. These are atherogenic lipoproteins and non-HDL cholesterol is a secondary target of treatment beyond LDL cholesterol in patients with hypertriglyceridemia. Some investigators favor total apolipoprotein B over non-HDL cholesterol as the secondary target of treatment. This is based on publications suggesting that total apolipoprotein B is more predictive of cardiovascular events than non-HDL cholesterol. Several methods are available for estimating total apolipoprotein B. This study compared total apolipoprotein estimated by immunonephelometric assay (INA), vertical auto profile (VAP), nuclear magnetic resonance (NMR), and non-HDL cholesterol levels in patients with hypertriglyceridemia from the previously reported Simvastatin plus Fenofibrate for Combined Hyperlipidemia (SAFARI) trial. Total apolipoprotein B levels were found to be highest by INA, intermediate by NMR and non-HDL cholesterol, and lowest by VAP. Concordance for non-HDL cholesterol levels among the INA, VAP, and NMR methods was better than that for total apolipoprotein B levels; the correlation between non-HDL cholesterol and apolipoprotein B by INA was strongest (0.929). In patients with a low triglyceride/HDL cholesterol ratio (<3.5), total apolipoprotein B determined by INA was higher than that estimated from non-HDL cholesterol levels, whereas in patients with a high triglyceride/HDL C ratio (≥3.5), apolipoprotein B predicted using non-HDL cholesterol was in better agreement with INA-determined apolipoprotein B levels. Similar trends were observed with VAP using equations specific for LDL particle size. In conclusion, more work is needed to improve agreement of apolipoprotein B measurements among methods employed clinically. Non-HDL cholesterol is also useful to predict total apolipoprotein B and some improvement may be attained by taking into account the ratio of triglyceride/HDL cholesterol as a measurement of LDL particle size.

Efficacy of apolipoprotein B synthesis inhibition in subjects with mild-to-moderate hyperlipidaemia

AIMS

Mipomersen, an apolipoprotein (apo) B synthesis inhibitor, has been shown to produce potent reductions in apoB and LDL-cholesterol levels in animal models as well as healthy human volunteers. A randomized, double-blind, placebo-controlled, dose-escalation study was designed to evaluate the efficacy and safety of mipomersen monotherapy with or without dose loading in subjects with mild-to-moderate hyperlipidaemia.

METHODS AND RESULTS

Fifty subjects with LDL-cholesterol levels between 119 and 266 mg/dL were enrolled into five cohorts at a 4:1 randomization ratio of active to placebo. Two 13-week dose regimens were evaluated at doses ranging from 50 to 400 mg/week. Mipomersen produced dose-dependent reductions in all apoB containing lipoproteins. In the 200 and 300 mg/week dose cohorts, mean reductions from baseline in LDL cholesterol were -45 ± 10% (P= 0.000) and -61 ± 8% (P= 0.000), corresponding to a -46 ± 11% (P= 0.000) and -61 ± 7% (P= 0.000) decrease in apoB levels. Triglyceride levels were also lowered with median reductions up to 53% (P= 0.021). The most common adverse events were injection site reactions. Seven of 40 subjects (18%) showed consecutive transaminase elevations >3× upper limit of normal. Five of these subjects received 400 mg/week, four of whom had apoB levels below the limit of detection. As a consequence, the 400 mg/week cohort was discontinued.

CONCLUSIONS

Mipomersen administered as monotherapy in subjects with mild-to-moderate hyperlipidaemia produced potent reductions in all apoB-containing lipoproteins. Higher doses were associated with hepatic transaminase increases.

Influence of simvastatin, fenofibrate and/or ezetimibe on correlation of low-density lipoprotein and nonhigh-density lipoprotein cholesterol with apolipoprotein B in mixed dyslipidemic patients

OBJECTIVES

Correlations between low-density lipoprotein cholesterol (LDL-C), or nonhigh-density lipoprotein cholesterol (non-HDL-C) and apolipoprotein B (Apo B) change after statin therapy has been initiated in hypercholesterolemic patients. This post-hoc analysis studied the correlation between these parameters in patients with mixed dyslipidemia before and after receiving lipid-lowering treatment.

RESULTS

Data from two randomized, double-blind studies of 1112 patients with mixed dyslipidemia receiving treatment (ezetimibe 10 mg, ezetimibe/simvastatin 10/20 mg, fenofibrate 160 mg, ezetimibe + fenofibrate 10/160 mg, or ezetimibe/simvastatin + fenofibrate 10/20/160 mg) were pooled. Correlation analyses and simple linear regression analyses were performed at baseline in untreated patients and after 12 weeks of treatment in the whole pooled population, the treatment groups, and after stratification by baseline triglyceride levels (150-250, ≥ 250 mg/dL) within the treatment groups. Both LDL-C and non-HDL-C were closely correlated with levels of Apo B at baseline, and these correlations improved after treatment. When using the fitted simple linear regression equations, we found that the on-treatment LDL-C and non-HDL-C levels corresponding to an Apo B of 90, 80, and 70 mg/dL were lower than proposed LDL-C and non-HDL-C treatment targets. For TG ≥ 250 mg/dL, the corresponding LDL-C was generally lower than that for triglycerides 150-250 mg/dL, except in the cases with fenofibrate in the treatment.

CONCLUSION

The results of these analyses suggest that achieving goal-specified levels of Apo B in statin-treated patients with mixed dyslipidemia would require more aggressive LDL-C lowering to achieve the greatest reduction in LDL particle number.

Low density lipoprotein cholesterol is inversely correlated with abdominal visceral fat area: a magnetic resonance imaging study

Background

Visceral Fat Area (VFA) is an independent predictor of coronary disease. While low density lipoprotein cholesterol (LDL-C) is used to determine risk and guide therapy, its accuracy fails in obese patients who may have low LDL-C despite high VFA.

Objective

We sought to describe the relationship between VFA, LDL-C and to describe shifting cholesterol metabolism with increasing VFA.

Methods

42 High-risk vascular patients not on lipid-lowering therapy provided a fasting lipid profile and underwent magnetic resonance imaging (MRI) to quantify VFA and subcutaneous fat area (SFA) at the L4-L5 disc. Comparisons: 1. Correlation between VFA, SFA, LDL-C and the standard lipid panel 2. Correlation between VFA, SFA and markers of cholesterol synthesis (desmosterol, lathosterol) and cholesterol absorption (cholestanol, sitosterol).

Results

VFA was inversely correlated with LDL-C (r = -0.348) indicating potential discordance between cardiovascular risk and LDL-C. However, VFA was appropriately correlated with other markers of increased risk: r = -0.361 with HDL-C, r = 0.503 with VLDL-C, r = 0.499 with TG (all p < 0.05). VFA did not correlate significantly with non-HDL-C. VFA correlated positively with cholesterol synthesis markers (desmosterol, lathosterol) and negatively with an absorption marker (cholestanol).

Conclusions

LDL-C is inversely correlated with VFA and this may explain the loss of the relationship between LDL-C and cardiovascular events in the obese. While Non-HDL-C did not correlate positively with VFA, the absence of a negative correlation suggests that it may be a more appropriate lipid target in an increasingly obese world.

Targeting residual risk: the rationale for the use of non-HDL cholesterol

There is a wealth of epidemiological and clinical data linking low-density lipoprotein cholesterol (LDLc) with atherosclerotic cardiovascular disease. Numerous primary and secondary prevention trials have demonstrated that reduction in LDLc leads to significant decrease in cardiovascular event rates. However, patients continue to be at significant risk for recurrent events despite aggressive LDLc lowering, reflecting a substantial residual risk. Numerous parameters like apolipoprotein B, LDL particle size, number and non-high density lipoprotein cholesterol (non-HDLc) measurement have been used to assess and address this high residual risk. Herein, we discuss the rationale and the evidence supporting the use of non-HDLc. We also discuss therapeutic options and provide a practical approach to residual risk reduction from a primary care perspective.

Atorvastatin affects low density lipoprotein and non-high density lipoprotein cholesterol relations with apolipoprotein B in type 2 diabetes mellitus: modification by triglycerides and cholesteryl ester transfer protein

OBJECTIVES

Non-HDL-cholesterol (non-HDL-C) and apolipoprotein (apo) B are proposed as treatment targets. The extent to which statin therapy affects relationships of LDL-C and non-HDL-C with apoB was examined in type 2 diabetes.

METHODS

Analyses were performed in 217 hypertriglyceridaemic type 2 diabetic patients (Diabetes Atorvastatin Lipid Intervention (DALI) cohort). 61 patients randomized to placebo, 70 to 10 mg atorvastatin daily and 65 - 80 mg atorvastin daily completed follow-up.

RESULTS

Baseline fasting LDL-C of 2.42 mmol/l and non-HDL-C of 3.69 mmol/l corresponded to the apoB guideline target of 0.90 g/l. During atorvastatin (10 and 80 mg daily), the LDL-C target was achieved most frequently, and lower LDL-C (2.38 and 2.29 mmol/l) and non-HDL-C (3.24 and 3.19 mmol/l) concentrations corresponded to this apoB goal. Decreases in LDL-C during atorvastatin treatment were negatively related (p < 0.001), but decreases in non-HDL-C were positively related to changes in triglycerides (p < 0.001), independently from decreases in apoB (p < 0.001 for all). Decreases in LDL-C and non-HDL-C were positively associated with decreases in cholesteryl ester transfer protein mass (p < 0.001).

CONCLUSIONS

During atorvastatin lower LDL-C and non-HDL-C levels correspond to the apoB guideline target, which would favour its use as treatment target.

Correlation of non-high-density lipoprotein cholesterol and low-density lipoprotein cholesterol with apolipoprotein B during simvastatin + fenofibrate therapy in patients with combined hyperlipidemia (a subanalysis of the SAFARI trial)

Guidelines have recommended non-high-density lipoprotein (non-HDL) cholesterol as a secondary target for therapy after the low-density lipoprotein (LDL) cholesterol goals have been met in patients with hypertriglyceridemia; non-HDL cholesterol is viewed as a surrogate for apolipoprotein (Apo)B, an alternate end point of treatment. The present analysis of the previously reported Simvastatin plus Fenofibrate for Combined Hyperlipidemia (SAFARI) trial assessed the associations of non-HDL cholesterol and LDL cholesterol with ApoB levels in patients with combined hyperlipidemia treated with combination simvastatin (20 mg) and fenofibrate (160 mg) or simvastatin monotherapy (20 mg). The correlations of these factors were analyzed in the overall modified intent-to-treat population (n = 594) and in patient subgroups stratified by triglyceride (TG) tertiles. Simvastatin plus fenofibrate and simvastatin alone significantly reduced LDL cholesterol, TG, non-HDL cholesterol and ApoB levels and non-HDL cholesterol/ApoB ratio (p < or =0.0004), regardless of the TG level. The greatest reductions occurred with combination treatment. The baseline levels of non-HDL cholesterol and LDL cholesterol correlated highly with ApoB and were stronger in the lower TG tertiles than in the higher TG tertiles. After 12 weeks, the correlations had changed little with simvastatin monotherapy but had increased substantially with combination therapy and were most improved at high TG levels. In conclusion, these results suggest that both non-HDL cholesterol and ApoB provide similar information in relation to treatment response in patients with combined hyperlipidemia and hypertriglyceridemia, and that non-HDL cholesterol is a good indicator of ApoB-containing lipoproteins, supporting its recommended use as a secondary therapeutic target in these patients.

Apolipoprotein B versus LDL-cholesterol: Association with other risk factors for atherosclerosis

OBJECTIVE

To characterize the differences in various risk factors for atherosclerosis between individuals with apoB higher (H) and lower (L) than predicted from regression equation apoB vs LDL-C.

METHODS

We evaluated 391 dyslipidemic subjects not treated with hypolipidemic drugs. The measured parameters included lipid profile, apolipoproteins A-1 and B, markers of insulin resistance and inflammation/hemostasis.

RESULTS

Correlation coefficient between apoB and LDL-C was 0.9 (p<0.0001). Individuals with H apoB compared to L apoB had significantly higher sex and age adjusted BMI, waist circumference, insulin, HOMA (fasting insulinglucose/22.5), C-peptide, proinsulin, PAI-1, sICAM-1, sVCAM-1, t-PA, vWF, frequency of metabolic syndrome and lower values of TC, LDL-C and HDL-C (p<0.05 to <0.001 for all parameters).

CONCLUSION

Individuals with apoB higher than predicted by their LDL-C levels are more insulin resistant and have more atherogenic risk profile. Thus, at least for dyslipidemic patients with high cardiometabolic risk, apoB is a more appropriate marker of risk than LDL-C.

Regulation of apoAI processing by procollagen C-proteinase enhancer-2 and bone morphogenetic protein-1

Given the increased prevalence of cardiovascular disease in the world, the search for genetic variations controlling the levels of risk factors associated with the development of the disease continues. Multiple genetic association studies suggest the involvement of procollagen C-proteinase enhancer-2 (PCPE2) in modulating HDL-C levels. Therefore biochemical and mechanistic studies were undertaken to determine whether there might be a basis for a role of PCPE2 in HDL biogenesis. Our studies indicate that PCPE2 accelerates the proteolytic processing of pro-apolipoprotein (apo) AI by enhancing the cleavage of the hexapeptide extension present at the N terminus of apoAI. Surface Plasmon Resonance and immunoprecipitation studies indicate that PCPE2 interacts with BMP-1 and pro-apoAI to form a ternary pro-apoAI/BMP-1/PCPE2 complex. The most favorable interaction among these proteins begins with the association of BMP-1 to pro-apoAI followed by the binding of PCPE2 which further stabilizes the complex. PCPE2 resides, along with apoAI, on the HDL fraction of lipoproteins in human plasma supporting a relationship between HDL and PCPE2. Taken together, the findings from our studies identify a new player in the regulation of apoAI post-translational processing and open a new avenue to the study of mechanisms involved in the regulation of apoAI synthesis, HDL levels, and potentially, cardiovascular disease.

Comprehensive whole-genome and candidate gene analysis for response to statin therapy in the Treating to New Targets (TNT) cohort

BACKGROUND

Statins are effective at lowering low-density lipoprotein cholesterol and reducing risk of cardiovascular disease, but variability in response is not well understood. To address this, 5745 individuals from the Treating to New Targets (TNT) trial were genotyped in a combination of a whole-genome and candidate gene approach to identify associations with response to atorvastatin treatment.

METHODS AND RESULTS

A total of 291 988 single-nucleotide polymorphisms (SNPs) from 1984 individuals were analyzed for association with statin response, followed by genotyping top hits in 3761 additional individuals. None was significant at the whole-genome level in either the initial or follow-up test sets for association with low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, or triglyceride response. In addition to the whole-genome platform, 23 candidate genes previously associated with statin response were analyzed in these 5745 individuals. Three SNPs in apoE were most highly associated with low-density lipoprotein cholesterol response, followed by 1 in PCSK9 with a similar effect size. At the candidate gene level, SNPs in HMGCR were also significant though the effect was less than with those in apoE and PCSK9. rs7412/apoE had the most significant association (P=6x10(-30)), and its high significance in the whole-genome study (P=4x10(-9)) confirmed the suitability of this population for detecting effects. Age and gender were found to influence low-density lipoprotein cholesterol response to a similar extent as the most pronounced genetic effects.

CONCLUSIONS

Among SNPs tested with an allele frequency of at least 5%, only SNPs in apoE are found to influence statin response significantly. Less frequent variants in PCSK9 and smaller effect sizes in SNPs in HMGCR were also revealed.

Targets of statin therapy: LDL cholesterol, non-HDL cholesterol, and apolipoprotein B in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS)

BACKGROUND

LDL can vary considerably in its cholesterol content; thus, lowering LDL cholesterol (LDLC) as a goal of statin treatment implies the existence of considerable variation in the extent to which statin treatment removes circulating LDL particles. This consideration is particularly applicable in diabetes mellitus, in which LDL is frequently depleted of cholesterol.

METHODS

Type 2 diabetes patients randomly allocated to 10 mg/day atorvastatin (n = 1154) or to placebo (n = 1196) for 1 year were studied to compare spontaneous and statin-induced apolipoprotein B (apo B) concentrations (a measure of LDL particle concentration) at LDLC and non-HDL cholesterol (non-HDLC) concentrations proposed as statin targets in type 2 diabetes.

RESULTS

Patients treated with atorvastatin produced lower serum apo B concentrations at any given LDLC concentration than patients on placebo. An LDLC concentration of 1.8 mmol/L (70 mg/dL) during atorvastatin treatment was equivalent to a non-HDLC concentration of 2.59 mmol/L (100 mg/dL) or an apo B concentration of 0.8 g/L. At the more conservative LDLC targets of 2.59 mmol/L (100 mg/dL) and 3.37 mmol/L (130 mg/dL) for non-HDLC, however, the apo B concentration exceeded the 0.9-g/L value anticipated in the recent Consensus Statement from the American Diabetes Association and the American College of Cardiology.

CONCLUSIONS

The apo B concentration provides a more consistent goal for statin treatment than the LDLC or non-HDLC concentration.

Implications of the obesity epidemic for lipid-lowering therapy: non-HDL cholesterol should replace LDL cholesterol as the primary therapeutic target

Obesity, metabolic syndrome and diabetes are conditions with increasing prevalence around the world. Cardiovascular risk in diabetics is often so high as to overlap with event rates observed in those with established coronary disease and this has lead to diabetes being classified as a coronary risk equivalent. However, despite the elevated risk of cardiovascular events associated with diabetes and the metabolic syndrome, these patients often have normal low density lipoprotein (LDL) cholesterol despite frequent increases in apolipoprotein B, triglycerides and nonhigh density lipoprotein (HDL) cholesterol. In contrast to LDL cholesterol, non-HDL cholesterol represents cardiovascular risk across all patient populations but is currently only recommended as a secondary target of therapy by the ATP III report for patients with hypertriglyceridemia. This article provides an overview of the studies that shown non-HDL cholesterol to be superior to LDL cholesterol in predicting cardiovascular events and presents the case for non-HDL cholesterol being the more appropriate primary target of therapy in the context of the obesity pandemic. Adopting non-HDL cholesterol as the primary therapeutic target for all patients will conceivably lead to an appropriate intensification of therapy for high risk patients with low LDL cholesterol.