LDL cholesterol is the principal target of lipid-lowering therapy. However, recent evidence has suggested more appropriate targets, including non-HDL cholesterol, apolipoprotein B (apo B), as well as ratios of cholesterol/HDL cholesterol, LDL cholesterol/HDL cholesterol, and apo B/apo AI. To assess whether these parameters are more appropriate treatment targets, Kastelein et al. compared the relationships of on-treatment levels of these parameters with the occurrence of cardiovascular events using data from 2 prospective, randomized clinical trials: the Treating to New Targets (TNT; n=10,001) and Incremental Decrease in End Points through Aggressive Lipid Lowering (IDEAL, n=8,888) trials. In those trials, patients with established coronary heart disease were assigned to usual-dose or high-dose statin treatment and followed for a median of 4.9 and 4.8 years, respectively. Post-hoc analysis showed that non-HDL cholesterol and apo B were more closely related to cardiovascular outcome than LDL cholesterol. Comparing non-HDL cholesterol to apo B revealed no significant difference. Moreover, the cholesterol/HDL cholesterol ratio and the apo B/apo AI ratio in particular were more closely associated with outcomes than any of the individual pro-atherogenic lipoprotein parameters. This data supports the use of non-HDL cholesterol or apo B as novel treatment targets of lipid-lowering therapy.
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