Role of non-high-density lipoprotein cholesterol in prevention of cardiovascular disease: updated evidence from clinical trials

PURPOSE OF REVIEW: Although current clinical practice and treatment guidelines focus on low-density lipoprotein cholesterol as the basis for diagnosing and treating atherogenic dyslipidemias, many persons who develop cardiovascular disease do not have substantially elevated low-density lipoprotein cholesterol levels but may have low levels of high-density lipoprotein cholesterol and elevated triglycerides. Assessment of non-high-density lipoprotein cholesterol level provides a measure of cholesterol contained in all atherogenic particles, including low-density lipoprotein, lipoprotein(a), and triglyceride-rich particles such as very low density lipoprotein, very low density lipoprotein remnants, and intermediate-density lipoprotein. In the third Adult Treatment Panel guidelines of the US National Cholesterol Education Program, non-high-density lipoprotein cholesterol was introduced as a secondary target of therapy in persons with high triglyceride levels. RECENT FINDINGS: A growing number of epidemiological studies and clinical trials have examined the relation between non-high-density lipoprotein cholesterol level and cardiovascular disease events. Non-high-density lipoprotein cholesterol has been shown to be a better predictor for cardiovascular events than low-density lipoprotein cholesterol, and trials of statin therapy have demonstrated reductions in non-high-density lipoprotein cholesterol as well as low-density lipoprotein cholesterol. SUMMARY: Clinical trial evidence indicates the importance of incorporating all atherogenic lipoprotein particles in risk stratification. Non-high-density lipoprotein cholesterol is the most readily available surrogate marker for assessment of these particles and may also be a potential target of lipid-altering therapy. Statin therapy, which has already been demonstrated to decrease cardiovascular morbidity and mortality, provides significant reductions in non-high-density lipoprotein cholesterol.