LOW-DENSITY-LIPOPROTEIN APHERESIS IMPROVES REGIONAL MYOCARDIAL PERFUSION IN PATIENTS WITH HYPERCHOLESTEROLEMIA AND EXTENSIVE CORONARY-ARTERY DISEASE - THE LDL-APHERESIS ATHEROSCLEROSIS REGRESSION STUDY (LAARS)

Objectives. In a randomized study we evaluated the effect of biweekly low density lipoprotein (LDL) apheresis plus simvastatin versus medica tion alone on regional myocardial perfusion. Background. In patients w ith severe hypercholesterolemia, diet and lipid-lowering drugs are oft en insufficient to achieve optimal LDL cholesterol values. Low density lipoprotein apheresis is a very effective lipid-lowering therapy. Ass essment of regional myocardial perfusion enables evaluation of the fun ctional state of the coronary circulation. Methods. We studied 42 pati ents with severe hypercholesterolemia and extensive coronary artery di sease who were randomized to diet and simvastatin with or without biwe ekly LDL apheresis. Regional myocardial perfusion was assessed by digi tal subtraction angiography with videodensitometric calculation of hyp eremic mean transit time (HMTT) of contrast medium at baseline and aft er 2 years of therapy. Results. Low density lipoprotein cholesterol de creased by 63% (to 3.0 mmol/liter) in the LDL apheresis group and by 4 7% (to 4.1 mmol/liter) in the medication group. Paired HMTT measuremen ts were assessed in 43 regions in the LDL apheresis group and 35 regio ns in the medication group, In the LDL apheresis group, regional HMTT decreased over 2 years from 3.35 +/- 1.18 (mean +/- SDI to 2.87 +/- 0. 82 s (-14%, p = 0.001), whereas no change in the medication group was observed: 2.95 +/- 1.06 to 2.96, +/- 0.90 s (p = NS), In the patient-b ased comparison, the mean change in HMTT was -0.45 s (-14%, p = 0,01) in the LDL apheresis group and -0.05 s (-2% p = NS) in the medication group, respectively, Only exercise-induced ischemia improved in the LD L apheresis group, Conclusions. Biweekly LDL apheresis plus simvastati n decreased time-averaged LDL cholesterol le,els by an additional 31% (1.1 mmol/liter) compared with medication alone, After 2 years of ther apy, regional myocardial perfusion improved in the LDL apheresis group and remained unchanged in the medication group, Thus, aggressive redu ction of LDL cholesterol has a favorable effect on regional myocardial perfusion and alleviates ischemia. (C) 1996 by the American College o f Cardiology