Harbor Bridge, Sydney 2-9-15

Three Sisters at Echo point 2-10-15

More validation of Niacin with Statin

Editorial on Niacin 2-2015

• Angiographic trials from the 1990s provide valuable information on the impact of LDL cholesterol reduction on atherosclerosis progression.
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• The CLAS (Cholesterol Lowering Atherosclerosis Study) angiographic trial tested niacin/colestipol therapy in the pre-statin era.
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• Visually appreciable angiographic progression was dramatically reduced with niacin/colestipol therapy in the CLAS trial.
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• Niacin is a viable therapeutic option for patients who are statin intolerant or who need additional LDL reduction after maximum statin therapy fails to achieve adequate reduction.

Niacin does, however, favorably alter atherosclerotic plaque architecture.

Update on Niacin

• 1.Low serum levels of HDL-C and high levels of non-HDL-C are frequent phenotypic features of patients with acute coronary syndromes and contribute significantly to residual risk after LDL-C lowering with statin therapy.
• 2.Adjuvant therapy with niacin in patients with stable ischemic heart disease and well-controlled atherogenic lipoprotein burden was shown not to be efficacious in both the AIM-HIGH and HPS-2 THRIVE trials. Niacin does, however, favorably alter atherosclerotic plaque architecture.
• 3.Low HDL-C is a reliable predictor of risk for recurrent events in patients who have sustained an acute coronary syndrome. Raising HDL-C with niacin does not appear to contribute to risk reduction. HDL-C is not currently a target of therapy and niacin should not be used to raise low HDL-C levels.
• 4.There is renewed interest in the atherogenicity of triglyceride enriched remnant lipoproteins. Non-HDL-C encompasses triglyceride-enriched lipoproteins such as VLDL-C remnants and IDL-C.
• 5.Recent meta-analyses and one post hoc analysis suggest that niacin therapy contributes to risk reduction in patients with mixed dyslipidemia characterized by elevated levels of triglyceride-enriched lipoproteins.
• 6.Consistent with guidelines from around the world (including those of the NLA) that emphasize risk stratified non-HDL-C goal attainment, niacin therapy can be considered in patients with established coronary disease on statin therapy but whose non-HDL-C still exceeds 100 mg/dL.