This paper by Taylor discusses recent imaging trials and their implication for the optimal management of HDL cholesterol. It is recognized that the unique biology of HDL cholesterol means that therapies to raise it should be able to induce regression of atherosclerosis. Presently, the primary pharmacotherapy for increasing HDL cholesterol is niacin. Niacin has been proven to regress atherosclerosis when used as monotherapy, in combination with a statin, as well as in combination with nonstatin therapies and fibrates. Insights into the atherosclerosis benefits of combining lipid-lowering therapy with niacin have come from imaging studies using quantitative coronary angiography, carotid ultrasound, and intravascular ultrasound. These studies have shown modest inverse correlations between the extent of HDL increase and atherosclerosis regression. The author emphasized that new HDL therapeutic agents, specifically new classes of agents for the treatment of dyslipidemia, must be demonstrated to be safe and effective, with efficacy clearly defined as improvements in clinical cardiovascular outcomes. Therefore, atherosclerosis imaging will be an important component of preclinical testing of these agents and in head-to-head testing of treatment strategies.
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