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Benefits of fibrate drugs in coronary heart disease patients with normal cholesterol levels.

Most young and middle-aged persons who develop coronary heart disease (CHD) have some form of dyslipidemia with mild to moderate increases in plasma cholesterol or triglyceride concentrations (or both), often accompanied by reduced concentrations of HDL cholesterol. In such patients, treatment with diet or drugs directed mainly at lowering the concentration of atherogenic lipoproteins reduces the progression of coronary artery atherosclerotic disease and associated clinical events and prolongs life.1 Although many patients with CHD have abnormalities affecting all of the major lipoprotein classes (VLDL, LDL, and HDL), in some only a single class is affected. Low HDL cholesterol is a powerful risk factor for CHD, even when total cholesterol concentrations are normal.2 Although low HDL cholesterol is usually accompanied by increased VLDL cholesterol and triglyceride concentrations in populations (but not by high concentrations of LDL cholesterol),3 isolated low HDL cholesterol is frequent in CHD patients.4 

How to manage patients with isolated low HDL cholesterol, particularly those with manifest atherosclerotic vascular disease, is unclear. Increased physical activity and judicious use of alcoholic beverages can increase HDL cholesterol, usually modestly. Drugs that increase HDL cholesterol generally lower atherogenic lipoprotein concentrations as well, and the benefit of such drug use is generally ascribed primarily to reduced concentrations of these lipoproteins, especially LDL. However, recent observational studies and some clinical trials have placed increased emphasis on changes in components of VLDL as determinants of the progression of coronary artery atherosclerosis, assessed angiographically. For example, in the …