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A new look at HDL in coronary disease: can we escape natural history?
  1. Stephan Gielen1,
  2. Ulf Landmesser2
  1. 1Department of Internal Medicine/Cardiology, Heart Center Leipzig, University Hospital, Leipzig, Germany
  2. 2Department of Cardiology, Cardiovascular Center, University Hospital Zurich, Switzerland
  1. Correspondence to Dr Stephan Gielen, Assistant Professor of Medicine, Heart Center Leipzig, University Hospital, Department of Internal Medicine/Cardiology, Struempellstrasse 39, Leipzig 04289, Germany; stephan.gielen{at}medizin.uni-leipzig.de

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Introduction

In this issue, Seo et al, on behalf of all participants in the COACT (Catholic University of Korea–percutaneous coronary intervention) registry, report that after placement of a drug-eluting stent in patients with coronary artery disease (CAD) and well controlled low-density lipoprotein (LDL-C) serum levels below 100 mg/dl, the high-density lipoprotein (HDL-C) serum concentrations remain a significant prognostic indicator of future cardiovascular events.1 The authors dichotomised the patient cohort according to HDL-C levels (40 mg/dl for men or 50 mg/dl for women) and compared major adverse cardiovascular event rates (MACE). Patients with low HDL-C levels (<40 mg/dl for men or <50 mg/dl for women) had a 40% higher rate of major adverse cardiac events (MACE), including all-cause death, non-fatal myocardial infarction and target vessel revascularisation (adjusted HR 1.404, 95% CI 1.111 to 1.774, p=0.004).

Their well conducted study confirms the results of a post-hoc analysis of the Treating to New Targets trial, in which a 39% lower risk for cardiovascular events was observed for patients with stable CAD in the highest versus lowest HDL-C quintile—even under statin therapy and LDL-C levels <100 mg/dl.2 In contrast to Treating to New Targets, however, Seo et al assessed the risk reduction in a post-interventional CAD cohort recruited for a national registry, thus reflecting a more ‘real-world’ scenario.

However, there are also some caveats in a registry as compared to a prospective randomised trial: patients with low HDL-C were more likely to present with acute coronary syndrome (ACS), had a 10.3% higher prevalence of diabetes mellitus, and a 5.8% higher prevalence of arterial hypertension (see their table 1). To exclude that the higher …

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