High density lipoprotein medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Treatment
Risk Assessment
Coronary Heart Disease
It has been established that HDL levels are inversely related to the risk of coronary artery disease and over all mortality caused by cardiovascular diseases. In a review of four important studies, it was documented that with increase in HDL levels by 1mg/dl, risk of coronary heart disease decreased by 2% in men and 3% in women. According to the review, mortality caused by cardiovascular diseases decreased by 3.7% in men and 4.7% in women with an increase in HDL levels by 1mg/dl.[1] American heart association recommends HDL level less than 50 mg/dl in women with increased CHD risk and a level of less than 40 mg/dl in men.
Risk assessment for CHD is done based on following factors:
- Increased total cholesterol and triglyceride level
- Total cholesterol/HDL ratio
- Diabetes mellitus
- Obesity
- Smoking
- Lack of physical activity
- Stress
Non-modifiable risk factors:
- Age
- Gender (male)
- Family history of premature coronary artery disease
Metabolic Syndrome
Metabolic syndrome has been described as group of disorders, a combination of which increases the risk of cardiovascular disease. These disorders include central obesity, increased waist circumference, hyperglycemia, dyslipidemia and high blood pressure. Low HDl along with hypertension has been identified as the most important metabolic syndrome risk factor for heart failure.[2]
Diabetes Mellitus
Persistently elevated blood glucose is associated with low level of HDL in type 2 diabetes mellitus.[3] According to American Diabetes Association, HDL should be maintained above 40 mg/dl in diabetics.
When To Treat
NCEP has not set a formal goal for HDL levels as a therapeutic target because of lack of evidence for decrease in primary CHD risk reduction with pharmacotherapy. Drug therapy for HDL can be considered in patients in presence of other risk factors for CHD such as hypertension, smoking, family history of premature coronary heart disease. The following are the ATP III guidelines for low HDL management (i.e., HDL-C≤40 mg/dl):
- First LDL goal should be achieved
- Weight reduction and physical exercise
- If triglycerides 200-499 mg/dL, achieve non-HDL goal
- If triglycerides <200 mg/dL (isolated low HDL) in CHD or CHD equivalent, consider nicotinic acid or fibrate
Treatment Options
Non-pharmacologic Therapies
Weight Loss
In a metanalysis of 70 studies,12% increase in HDL was observed in subjects with stable reduced weight.[4]
Smoking Cessation
Smoking increases activity of CETP enzyme and lowers activity of LCAT, which results in reduced amount of HDL. In a study done by Gepner et al, smoking cessation increased HDL level by 5.2%.[5]
Alcohol Consumption
Moderate amount of alcohol consumption can result in increased HDL, however, it also leads to increased triglycerides.
Exercise
Physical activity increases HDL level, increased amount of LPL enzyme is one of the suggested mechanism.[6]
Pharmacologic Therapies
Dietary Measures
| DIET | EFFECT ON HDL |
| Multivitamins | 31% increase in HDL |
| DASH diet | 21% increase in HDL |
| Low carbohydrate diets | 10% increase in HDL |
| Soy protein with isoflavones | 3% increase in HDL |
| Fish oil (omega-3 fatty acid) | Significant increase in HDL2 fraction[7] |
| Fish oil with exercise | 8% increase in HDL[8] |
| AHA step 1 diet | |
| Low fat diet | 5-14% increase in HDL when combined with exercise[9] |
Medications
| Drugs | MECHANISM OF ACTION | EFFECT ON HDL-C | SIDE EFFECTS |
| Nicotinic acid (Niacin) | |||
| Fibric acid derivatives | |||
| HMG CoA reductase inhibitors | |||
| Ezetimibe | |||
| Thiazolidinediones | |||
| Hormone replacement therapy |
| INVESTIGATIONAL DRUGS | MECHANISM OF ACTION | EFFECT ON HDL-C | SIDE EFFECTS |
| Endocannabinoid receptor blockers | |||
| ApoA-1 Milano | |||
| CETP Inhibitors | |||
| CETi-1 Vaccine | |||
| JTT-705 | |||
| CER-001 | |||
| CSL-112 |
References
- ↑ Gordon DJ, Probstfield JL, Garrison RJ, Neaton JD, Castelli WP, Knoke JD; et al. (1989). "High-density lipoprotein cholesterol and cardiovascular disease. Four prospective American studies". Circulation. 79 (1): 8–15. PMID 2642759.
- ↑ Karadag MK, Akbulut M (2009). "Low HDL levels as the most common metabolic syndrome risk factor in heart failure". Int Heart J. 50 (5): 571–80. PMID 19809206.
- ↑ Gatti A, Maranghi M, Bacci S, Carallo C, Gnasso A, Mandosi E; et al. (2009). "Poor glycemic control is an independent risk factor for low HDL cholesterol in patients with type 2 diabetes". Diabetes Care. 32 (8): 1550–2. doi:10.2337/dc09-0256. PMC 2713640. PMID 19487641.
- ↑ Dattilo AM, Kris-Etherton PM (1992). "Effects of weight reduction on blood lipids and lipoproteins: a meta-analysis". Am J Clin Nutr. 56 (2): 320–8. PMID 1386186.
- ↑ Gepner AD, Piper ME, Johnson HM, Fiore MC, Baker TB, Stein JH (2011). "Effects of smoking and smoking cessation on lipids and lipoproteins: outcomes from a randomized clinical trial". Am Heart J. 161 (1): 145–51. doi:10.1016/j.ahj.2010.09.023. PMC 3110741. PMID 21167347.
- ↑ Thompson PD (1990). "What do muscles have to do with lipoproteins?". Circulation. 81 (4): 1428–30. PMID 2317921.
- ↑ Sacks FM, Hebert P, Appel LJ, Borhani NO, Applegate WB, Cohen JD; et al. (1994). "The effect of fish oil on blood pressure and high-density lipoprotein-cholesterol levels in phase I of the Trials of Hypertension Prevention. Trials of Hypertension Prevention Collaborative Research Group". J Hypertens Suppl. 12 (7): S23–31. PMID 7769501.
- ↑ Herrmann W, Biermann J, Kostner GM (1995). "Comparison of effects of N-3 to N-6 fatty acids on serum level of lipoprotein(a) in patients with coronary artery disease". Am J Cardiol. 76 (7): 459–62. PMID 7653444.
- ↑ Varady KA, Jones PJ (2005). "Combination diet and exercise interventions for the treatment of dyslipidemia: an effective preliminary strategy to lower cholesterol levels?". J Nutr. 135 (8): 1829–35. PMID 16046704.