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Does HDL Matter When Statins Are Working?

In a post hoc analysis of TNT trial data, HDL levels predicted cardiovascular events in patients with very low LDL levels.

Little information is available about risk for cardiovascular events in patients who are treated aggressively with statins. In particular, does HDL retain its strong prognostic value in patients with very low LDL levels? To find out, investigators from the Treating to New Targets (TNT) trial, in which 2661 participants achieved LDL cholesterol levels below 70 mg/dl (Journal Watch Cardiology Dec 30 2005), analyzed post hoc the relationship between HDL cholesterol levels and major cardiovascular events.

A total of 9770 study patients (age range, 35 to 75) with clinically evident coronary artery disease were stratified by quintile of HDL cholesterol level at 3 months of statin treatment. In multivariable analysis, HDL quintile at month 3 was a strong and significant predictor of cardiovascular events. Patients in the highest quintile (55 mg/dL) had a 25% lower risk for cardiovascular events than those in the lowest quintile (<38 mg/dL). This relationship was independent of statin dose or LDL level. The ratio of LDL cholesterol to HDL cholesterol at 3 months was also strongly and significantly predictive of cardiovascular events. Subjects with the lowest LDL:HDL ratios (<1.33) experienced fewer than half as many events as those with the highest ratios (2.41).

Comment: HDL cholesterol levels have prognostic importance even in patients in whom aggressive statin treatment has achieved low LDL cholesterol levels. Clinicians should remain alert to all known cardiovascular risk factors when using statins to treat patients with coronary artery disease.

— Harlan M. Krumholz, MD, SM

Published in Journal Watch Cardiology September 26, 2007

Citation(s):

Barter P et al. for the Treating to New Targets Investigators. HDL cholesterol, very low levels of LDL cholesterol, and cardiovascular events. N Engl J Med 2007 Sep 27; 357:1301.

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