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High Density Lipoprotein Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]; Raviteja Guddeti, M.B.B.S. [3]

Overview

Pathophysiology

Causes

Epidemiology and Demographics

Low HDL and Cardiovascular Risk

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Treatment

Landmark Trials | Medical Therapy | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

Overview

High-density lipoproteins (HDL) form a class of lipoproteins, varying somewhat in their size (8–11 nm in diameter), that carry cholesterol from the body's tissues to the liver. About thirty percent of blood cholesterol is carried by HDL.[1]

It is hypothesised that HDL can remove cholesterol from atheroma within arteries and transport it back to the liver for excretion or re-utilization—which is the main reason why HDL-bound cholesterol is sometimes called "good cholesterol", or HDL-C. A high level of HDL-C seems to protect against cardiovascular diseases, and low HDL cholesterol levels (less than 40 mg/dL) increase the risk for heart disease.[1] When measuring cholesterol, any contained in HDL particles is considered as protection to the body's cardiovascular health, in contrast to "bad" LDL cholesterol.

Structure and function

HDL are the smallest of the lipoproteins. They are the densest because they contain the highest proportion of protein. They contain the A class of apolipoproteins.[2] The liver synthesizes these lipoproteins as complexes of apolipoproteins and phospholipid, which resemble cholesterol-free flattened spherical lipoprotein particles. They are capable of picking up cholesterol, carried internally, from cells they interact with. A plasma enzyme called lecithin-cholesterol acyltransferase (LCAT) converts the free cholesterol into cholesteryl ester (a more hydrophobic form of cholesterol) which is then sequestered into the core of the lipoprotein particle eventually making the newly synthesized HDL spherical. They increase in size as they circulate through the bloodstream and incorporate more cholesterol molecules into their structure. Thus it is the concentration of large HDL particles which more accurately reflects protective action, as opposed to the concentration of total HDL particles.[3] This ratio of large HDL to total HDL particles varies widely and is only measured by more sophisticated lipoprotein assays using either electrophoresis (the original method developed in the 1970s), or newer NMR spectroscopy, NMR spectroscopy methods, developed in the 1990s.

HDL particles are not inherently protective. It is only the HDL particles which become the largest (actually picking up and carrying cholesterol) which are protective. There is no reliable relationship between total HDL and large HDL, and more sophisticated analyses which actually measure large HDL, not just total, correlate much better with clinical outcomes.

In the stress response, serum amyloid A, which is one of the acute phase proteins and an apolipoprotein, is under the stimulation of cytokines (IL-1, IL-6) and cortisol produced in the adrenal cortex and carried to the damaged tissue incorporated into HDL particles. At the inflammation site, it attracts and activates leukocytes. In chronic inflammations, its deposition in the tissues manifests itself as amyloidosis.

Men tend to have noticeably lower HDL levels, with smaller size and lower cholesterol content, than women. Men also have an increased incidence of atherosclerotic heart disease.

Historically, beginning in the late 1970's cholesterol and lipid assays were promoted to estimate total HDL-cholesterol because such tests used to be far less expensive, by about 50 fold, than measured lipoprotein particle concentrations and subclass analysis. Over time, with continued research, decreasing costs, greater availability and wider acceptance of other "lipoprotein subclass analysis" assay methods, including NMR spectroscopy, human studies have continued to show a stronger correlation between human clinically obvious cardiovascular events and quantitatively measured large HDL-particle concentrations.

Epidemiology

Epidemiological studies have shown that high concentrations of HDL (over 60 mg/dL) have protective value against cardiovascular diseases such as ischemic stroke and myocardial infarction. Low concentrations of HDL (below 40 mg/dL for men, below 50 mg/dL for women) are a positive risk factor for these atherosclerotic diseases.

Data from the landmark Framingham Heart Study showed that for a given level of LDL, the risk of heart disease increases 10-fold as the HDL varies from high to low. Conversely, for a fixed level of HDL, the risk increases 3-fold as LDL varies from low to high.

Recommended range

The American Heart Association, NIH and NCEP provides a set of guidelines for male fasting HDL levels and risk for heart disease.

Level mg/dL Level mmol/L Interpretation
<40 <1.03 Low HDL cholesterol, heightened risk for heart disease, <50 is the value for women
40–59 1.03–1.52 Medium HDL level
>60 >1.55 High HDL level, optimal condition considered protective against heart disease

More sophisticated laboratory methods measure not just the total HDL but also the range of HDL particles, e.g. "lipoprotein subclass analysis", typically divided into several groups by size, instead of just the total HDL concentration as listed above. The largest groups (most functional) of HDL particles have the most protective effects. The groups of smallest particles reflect HDL particles which are not actively transporting cholesterol, thus not protective.

Differential Diagnosis

  • HDL cholesterol is a positive cardiac Risk Factors
    • 'HDL < 35
    • Total cholesterol to HDL ratio in > 5.0 (in men)
    • Total cholesterol to HDL ratio in > 4.5 (in women)
  • Negative cardiac risk factor if HDL > 60

Decreased

Increased

  • Drugs
  • Moderate alcohol intake
  • Regular aerobic exercise
  • Weight loss

Raising HDL

Drugs

As of 2006, randomized clinical trials have demonstrated significant reduction of atherosclerosis progression and cardiovascular events with treatments that increase HDL-cholesterol (nicotinic acid or a fibrate).[4]

Pharmacological therapy to increase the level of HDL cholesterol includes use of fibrates and niacin. Consumption of niacin, an immediate release crystalline form of Vitamin B3, can increase HDL levels by 10–30%, and is the most powerful agent currently available to increase HDL-cholesterol.[4][5] [6] The use of statins is effective against high levels of LDL cholesterol, but it has little or no effect in raising HDL-cholesterol. [5] The use of antioxidants in combination with statin and niacin therapy reduces the effectiveness of niacin by 33%. (NIH HATS).

Torcetrapib

The development of torcetrapib, a drug developed by Pfizer to raise HDL by inhibition of cholesteryl ester transfer protein (CETP), was terminated after a greater percentage of patients treated with torcetrapib-Lipitor combination died compared with patients treated with Lipitor alone. The adverse results were thought to be mediated by off target toxicity associated with torcetrapib, namely the elevation of blood pressure due to an impact on the renin angiotensin axis.

Niaspan

The NIH-sponsored AIM High study failed to demonstrate a benefit of Niaspan.

Dalcetrapib

Dalcetrapib raises high-density lipoprotein or HDL by 25%-30% and has minimal effect on LDL. The DAL Outcomes 2 trial was discontinued early by the data safety monitoring committee for futility.

Anacetrapib

Anacetrapib raises HDL by 138%, and lowers LDL by 35% to 40%.

Evacetrapib

evacetrapib raises HDL by 130% and lowers LDL by 35% to 40%.

Diet and lifestyle

Certain changes in lifestyle can have a positive impact on raising HDL levels:[7]

See also

References

  1. 1.0 1.1 http://www.americanheart.org/presenter.jhtml?identifier=180
  2. Baylor College of Medicine, Lipids Online (January 29, 2001). "Heterogeneity of HDL".
  3. Kwiterovich PO. The Metabolic Pathways of High-Density Lipoprotein, Low-Density Lipoprotein, and Triglycerides: A Current Review. Am J Cardiol 2000;86(suppl):5L.
  4. 4.0 4.1 Reducing risk by raising HDL-cholesterol: the evidence. # European Heart Journal Supplements Vol 8 Suppl F p. F23-F29 http://eurheartjsupp.oxfordjournals.org/cgi/content/abstract/8/suppl_F/F23
  5. 5.0 5.1 Raising HDL-Cholesterol and Reducing Cardiovascular Risk. Medscape Cardiology http://www.medscape.com/viewarticle/520393
  6. Chapman M, Assmann G, Fruchart J, Shepherd J, Sirtori C. Raising high-density lipoprotein cholesterol with reduction of cardiovascular risk: the role of nicotinic acid - a position paper developed by the European Consensus Panel on HDL-C. Cur Med Res Opin. 2004 Aug;20(8):1253-68. PMID 15324528
  7. Richard N. Fogoros, M.D. "Raising Your HDL Levels".
  8. Spate-Douglas, T., Keyser, R. E. Exercise intensity: its effect on the high-density lipoprotein profile. Arch Phys Med Rehabil 80, 691-695. PMID 10378497


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de:HDL (Medizin) it:Lipoproteine ad alta densità sv:Low density lipoprotein



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