Non-HDL cholesterol as a therapeutic goal. / Colesterol-no HDL como objetivo terapéutico.

Although cholesterol linked to low-density lipoproteins (c-LDL) is well established as a risk factor for cardiovascular disease, there is often a more complex dyslipidaemia pattern that contributes to the formation of atherosclerotic plaque. Non-HDL cholesterol (c-NO-HDL) is used to estimate the total amount of atherogenic lipoproteins in plasma, some of which are not usually determined in daily clinical practice. c-NO-HDL is easily calculated from the subtraction of total plasma cholesterol from the cholesterol content carried by high density lipoproteins. The c-NO-HDL has a predictive value superior to that of C-LDL to estimate the risk of major cardiovascular events in epidemiological studies. Genetic studies by analysis of the complete genome, together with those based on Mendelian randomisation, point to the aetiological character of c-NO-HDL on ischaemic heart disease (IHD). Intervention studies, and the meta-analyses derived from them, close the causal circle between c-NO-HDL and IHD, by demonstrating that any intervention that decreases the concentrations of the former reduces the incidence of arteriosclerotic heart disease. The European ESC/EAS 2016 guide for the management of dyslipidaemia considers c-NO-HDL as a therapeutic target with a Class IIa recommendation (should be performed) Level B (data from a single randomised clinical trial [RCT]) or from several non-RCTs), and sets its target at less than 100 or 130mg/dL for those patients with very high risk or high risk, respectively. These achievable c-NO-HDL values are easily calculated by adding 30mg/dL to the c-LDL targets.

Fibrates in primary prevention of cardiovascular disease. Comments on the results of a systematic review of the Cochrane Collaboration. / Los fibratos en la prevención primaria de la enfermedad cardiovascular. Comentarios a los resultados de una revisión sistemática de la Colaboración Cochrane.

Fibrates are drugs that reduce triglycerides, elevate high-density lipoproteins, as well as decrease small, dense LDL particles. The results of a study have recently been published by the Cochrane Collaboration on fibrates efficacy and safety in the primary prevention of cardiovascular disease. This study includes a systematic review and a meta-analysis of 6 studies (16,135 patients) that evaluated the clinical benefits of fibrates compared to placebo use or other lipid-lowering drugs. This review showed evidence of a protective effect of the fibrates compared with placebo as regards a reduction 16% of a compound objective of death due to cardiovascular disease, non-fatal myocardial infarction, or non-fatal cerebrovascular accident (NNT: 112), and that reduce coronary morbidity and mortality by 21% (NNT: 125). In addition, fibrates could reduce previously established diabetic retinopathy. However, fibrates do not influence total mortality, or non-cardiovascular mortality. Its joint use with statins does not benefit patients without established cardiovascular disease, compared to the use of statins in monotherapy. Fibrates are safe, although they can elevate serum creatinine levels.

[Fibrates therapy: Rational use fenofibrate 2016. Executive summary]. / Terapia con fibratos: uso racional del fenofibrato 2016. Resumen ejecutivo.

To control lipid factors risk, beyond proper management of LDL cholesterol according to individual risk, detection and treatment of atherogenic dyslipidemia and abnormal levels of triglycerides or HDL cholesterol it should be considered for address a global cardiovascular protection, both in primary and secondary prevention. In this sense, these recommendations collect data on efficacy and safety about the combination statin with fibrates, often necessary for total control of dyslipidemia, particularly in patients with metabolic disorders such as diabetes mellitus, metabolic syndrome or visceral obesity. Reference to control and monitoring of treatment is also done, as well as benefits of fenofibrate not linked directly to their lipid-lowering effect.

Colesterol-no HDL como objetivo terapéutico / Non-HDL cholesterol as a therapeutic goal

Aunque el colesterol unido a las lipoproteínas de baja densidad (c-LDL) está bien establecido como un factor de riesgo de las enfermedades cardiovasculares; existe frecuentemente un patrón dislipidémico más complejo que contribuye a la formación de la placa arteriosclerótica. El colesterol no HDL (c-NO-HDL) se utiliza para la estimación de la cantidad total de lipoproteínas aterogénicas en plasma, algunas de las cuales no son determinadas habitualmente en la práctica clínica diaria. El c-NO-HDL se calcula fácilmente a partir de la sustracción de la cifra de colesterol total plasmático el contenido de colesterol vehiculizado por las lipoproteínas de alta densidad. El c-NO-HDL presenta una superioridad predictora sobre el c-LDL para estimar el riesgo de eventos cardiovasculares mayores en los estudios epidemiológicos. Los estudios genéticos mediante análisis del genoma completo, junto a los basados en la aleatorización mendeliana, apuntan al carácter etiológico del c-NO-HDL sobre la cardiopatía isquémica (CI). Los estudios de intervención, y los metaanálisis de ellos derivados, cierran el círculo causal entre c-NO-HDL y CI al demostrar que cualquier intervención que haga disminuir las concentraciones del primero aminora la incidencia de la cardiopatía arteriosclerótica. La guía europea ESC/EAS 2016 para el manejo de las dislipidemias contempla al c-NO-HDL como una diana terapéutica con una recomendación clase iia (debería realizarse), nivel B (datos de un único RCT o de varios no RCT), y fija su objetivo en menor de 100 o 130 mg/dl para aquellos pacientes con muy alto riesgo o alto riesgo, respectivamente. Estos valores a lograr de c-NO-HDL se calculan fácilmente añadiendo 30 mg/dl a los objetivos c-LDL

Although cholesterol linked to low-density lipoproteins (c-LDL) is well established as a risk factor for cardiovascular disease, there is often a more complex dyslipidaemia pattern that contributes to the formation of atherosclerotic plaque. Non-HDL cholesterol (c-NO-HDL) is used to estimate the total amount of atherogenic lipoproteins in plasma, some of which are not usually determined in daily clinical practice. c-NO-HDL is easily calculated from the subtraction of total plasma cholesterol from the cholesterol content carried by high density lipoproteins. The c-NO-HDL has a predictive value superior to that of C-LDL to estimate the risk of major cardiovascular events in epidemiological studies. Genetic studies by analysis of the complete genome, together with those based on Mendelian randomisation, point to the aetiological character of c-NO-HDL on ischaemic heart disease (IHD). Intervention studies, and the meta-analyses derived from them, close the causal circle between c-NO-HDL and IHD, by demonstrating that any intervention that decreases the concentrations of the former reduces the incidence of arteriosclerotic heart disease. The European ESC/EAS 2016 guide for the management of dyslipidaemia considers c-NO-HDL as a therapeutic target with a Class IIa recommendation (should be performed) Level B (data from a single randomised clinical trial [RCT]) or from several non-RCTs), and sets its target at less than 100 or 130mg/dL for those patients with very high risk or high risk, respectively. These achievable c-NO-HDL values are easily calculated by adding 30 mg/dL to the c-LDL targets

Los fibratos en la prevención primaria de la enfermedad cardiovascular. Comentarios a los resultados de una revisión sistemática de la Colaboración Cochrane / Fibrates in primary prevention of cardiovascular disease. Comments on the results of a systematic review of the Cochrane Collaboration

Los fibratos son un grupo de hipolipidemiantes que reducen los triglicéridos, elevan las lipoproteínas de alta densidad y disminuyen la fracción de partículas de LDL pequeñas y densas. Recientemente, se han publicado los resultados de un estudio de la Colaboración Cochrane sobre su eficacia y seguridad en la prevención primaria de la enfermedad cardiovascular. Este estudio incluye una revisión sistemática y un metaanálisis de 6 estudios (16.135 pacientes) que evalúan, en personas en prevención primaria, los beneficios clínicos de los fibratos comparados con el uso de un placebo o de otros hipolipidemiantes. Concluyen que, comparados con placebo, los fibratos son útiles para reducir en un 16% el combinado muerte por enfermedad cardiovascular, infarto de miocardio no fatal o accidente cerebrovascular no fatal (NNT: 112) y que disminuyen la morbimortalidad coronaria un 21% (NNT: 125). Complementariamente, los fibratos podrían reducir la retinopatía diabética previamente establecida. Sin embargo, no influyen en la mortalidad total ni en la de origen no cardiovascular. Tampoco su empleo conjunto con estatinas beneficia a pacientes sin enfermedad cardiovascular establecida, comparado con el uso de estatinas en monoterapia. Los fibratos son seguros, aunque pueden elevar los niveles séricos de creatinina

Fibrates are drugs that reduce triglycerides, elevate high-density lipoproteins, as well as decrease small, dense LDL particles. The results of a study have recently been published by the Cochrane Collaboration on fibrates efficacy and safety in the primary prevention of cardiovascular disease. This study includes a systematic review and a meta-analysis of 6 studies (16,135 patients) that evaluated the clinical benefits of fibrates compared to placebo use or other lipid-lowering drugs. This review showed evidence of a protective effect of the fibrates compared with placebo as regards a reduction 16% of a compound objective of death due to cardiovascular disease, non-fatal myocardial infarction, or non-fatal cerebrovascular accident (NNT: 112), and that reduce coronary morbidity and mortality by 21% (NNT: 125). In addition, fibrates could reduce previously established diabetic retinopathy. However, fibrates do not influence total mortality, or non-cardiovascular mortality. Its joint use with statins does not benefit patients without established cardiovascular disease, compared to the use of statins in monotherapy. Fibrates are safe, although they can elevate serum creatinine levels

Terapia con fibratos: uso racional del fenofibrato 2016. Resumen ejecutivo / Fibrates therapy: Rational use fenofibrate 2016. Executive summary

En el control de los factores de riesgo lipídicos, y con independencia de un correcto manejo del cLDL acorde con el nivel de riesgo individual, se debe considerar la detección y tratamiento de la dislipidemia aterogénica y de los niveles anormales de triglicéridos o de cHDL para abordar una protección cardiovascular global, tanto en prevención primaria como secundaria. En tal sentido, estas recomendaciones recogen los datos de eficacia y seguridad de la combinación de estatina con los fibratos, frecuentemente necesaria para el control global de la dislipidemia, especialmente en los enfermos con alteraciones metabólicas tales como diabetes mellitus, síndrome metabólico u obesidad visceral. También se hace referencia al proceso de control y seguimiento del tratamiento, así como al valor añadido que pueden aportar los beneficios derivados del tratamiento con fenofibrato, que no se ligan directamente a su efecto hipolipemiante

To control lipid factors risk, beyond proper management of LDL cholesterol according to individual risk, detection and treatment of atherogenic dyslipidemia and abnormal levels of triglycerides or HDL cholesterol it should be considered for address a global cardiovascular protection, both in primary and secondary prevention. In this sense, these recommendations collect data on efficacy and safety about the combination statin with fibrates, often necessary for total control of dyslipidemia, particularly in patients with metabolic disorders such as diabetes mellitus, metabolic syndrome or visceral obesity. Reference to control and monitoring of treatment is also done, as well as benefits of fenofibrate not linked directly to their lipid-lowering effect