Lipid-Modifying and Antiatherosclerotic Drugs

Blood lipid assessment forms an essential step in the evaluation of almost every cardiac patient, whether middle-aged or elderly. Risk factor assessment is integral to the cardiovascular management of all patients: Physicians may help guide younger patients toward long-term cardiovascular health by addressing early risk factors, while middleaged and older patients may need a more intensive approach because of their near-term risk for coronary disease. The widespread availability, persuasive and substantial clinical database, and relative safety of the statins have established pharmacologic control of blood lipids as an increasingly acceptable strategy. Of the lipid aims, the early reduction of low-density-lipoprotein cholesterol (LDL-C) levels by statins is the current key to lessening clinical cardiovascular disease.2–4 Since the last edition of this book, direct measurement of the coronary atheroma volume by intravascular ultrasound has shown signifi cant regression of atherosclerosis when LDL-C levels fall less than 70 mg/dl (<1.8 mmol/L) and when accompanied by signifi cant increases in high-density-lipoprotein cholesterol (HDL-C).5 Although it is unclear how these fi ndings will translate into clinical outcomes, they are indicative of two major trends in current research: (1) the potential benefi t of high-intensity therapy to very low LDL-C levels, and (2) the increasing signifi cance of HDL-C as a potential therapeutic target.6 Combined with recent research focusing on the interactive roles of vascular infl ammation and endothelial damage in the genesis of arterial disease (Fig. 10-1),7 these developments are helping to refi ne current methods of cardiovascular risk assessment.