Treatment of dyslipidaemia in high-risk patients: too little, too late.

Evidence that lowering low-density cholesterol (LDL-C) reduces coronary events and mortality is now overwhelming and is reflected in treatment guidelines from around the world. The Joint European Guidelines recommend an LDL-C goal of <3.0 mmol/l in high-risk subjects. The National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP)-III guidelines suggest an even more aggressive approach in high-risk individuals, with a recommended LDL-C goal of <2.6 mmol/l. Large numbers of high-risk patients are still not achieving the more conservative goals recommended in the Joint European Guidelines, let alone the more aggressive LDL-C target recommended in the new NCEPATP-III guidelines. The recognition in the NCEP ATP-III guidelines that a high-density lipoprotein cholesterol (HDL-C) level <1.0 mmol/l represents an important risk factor highlights the emergence of HDL-C as a key player in the genesis of coronary heart disease (CHD) and as a potential target for therapy. This may be especially important in people with insulin resistance with or without type 2 diabetes. There is evidence from the Helsinki Heart Study and the more recent Veterans Affairs HDL Intervention Trial (VA-HIT), both of which used gemfibrozil as the active agent, that the observed reduction in coronary events was correlated with the magnitude of the increase in HDL-C. The challenge for future management of high-risk individuals will be not only to reduce the level of LDL-C to below 2.6 mmol/l but also to increase HDL-C to levels above 1.0 mmol/l.