Identifying patients at risk for coronary heart disease: implications fromtrials of lipid-lowering drug therapy

Abnormal lipid levels contribute significantly to the risk of coronary hear t disease (CHD), which is increased further in the presence of other risk f actors. The association between elevated low-density lipoprotein (LDL) chol esterol and CHD risk is well established, and large primary and secondary p revention studies of HMG-CoA reductase inhibitors (statins) have shown conc lusively that lowering LDL cholesterol levels reduces Ct-in events and tota l mortality. Regardless of the intervention used (diet, surgery, drugs), re duction of plasma cholesterol has consistently produced a reduction in card iovascular risk. Absolute benefit is greatest in those who are at highest r isk initially, and trial results suggest that the lower the LDL cholesterol level achieved, at least down to LDL of 3.0 mmol/l, then the lower is the CHD event risk. Epidemiological data also point to the negative impact of o ther lipids on CHD risk. Low levels of high-density lipoprotein (HDL) and h igh levels of triglycerides (particularly in conjunction with an LDL/HDL ra tio >5) are particularly strong risk factors for CHD. Thus, although preven tion trials to date have primarily assessed the impact of LDL lowering on C HD events, the initial assessment of CHD risk should consider a more detail ed atherogenic profile including HDL and triglyceride levels. A general app roach to preventing cardiovascular disease should include strategies to red uce the overall CHD risk by lifestyle modification and management of modifi able risk factors such as smoking, hypertension and diabetes. Based on data from recent prevention studies, and because they are the most potent lipid -lowering agents available for lowering LDL cholesterol, statins have appro priately become the drug of choice for most patients with hyperlipidaemia w ho require drug therapy.