Raising highly desirable lipoprotein versus lowering deleterious lipoprotein

Evaluation of: Taylor AJ, Villines TC, Stanek EJ et al. Extended-release niacin or ezetimibe and carotid intima-media thickness. N. Engl. J. Med. 361(22), 2113-2122 (2009). Epidemiological evidence suggests that elevated low-density lipoprotein cholesterol (LDL-C) and reduced high-density lipoprotein cholesterol (HDL-C) are both factors causing coronary heart disease. These authors compared extended-release niacin, which raises HDL-C, with ezetimibe, which lowers LDL-C, in a study named Arterial Biology for the Investigation of the Treatment Effects of Reducing Cholesterol 6-HDL and LDL Treatment Strategies (ARBITER 6-HALTS). The study was terminated early and only 208 patients were included in the analysis. Ezetimibe decreased LDL-C by 19.2%, to 66 mg/dl (1.7 mmol/l), whereas niacin increased HDL-C by 18.4%. Ezetimibe did not reduce carotid intima-media thickness, whereas niacin decreased it significantly. Moreover, major adverse cardiovascular events occurred in 5% of the ezetimibe group but only 1% of the niacin group (p = 0.04). The study suggests that niacin may be more effective than ezetimibe as an adjunct to statin in regressing atherosclerosis and in preventing cardiovascular events. This small study of short duration reported a very large treatment effect, so the findings need to be confirmed in a larger longer trial. Nevertheless, it provides the evidence that we now have an additional class of drugs besides statins that can reduce atherosclerosis and cardiovascular events.