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Johns Hopkins authors issue guidelines for raising HDL
An article by Johns Hopkins cardiologist Roger Blumenthal, MD, and nurse practitioner Dominique Ashen, PhD, CRNP, published in the September 22 2005 issue of the New England Journal of Medicine offers guidelines on how to raise high-density lipoprotein, or HDL cholesterol the “good” form of cholesterol that is protective against atherosclerosis. Most guidelines for cardiovascular disease prevention have strongly focused on lowering low-density lipoprotein, or LDL cholesterol, which is associated with arterial plaque formation when elevated. It is estimated that over 54 million people in the United States have less than desirable HDL levels (less than 40 milligrams per deciliter of blood for men and 50 milligrams per deciliter for women).
Dr Blumenthal, who is director of the Ciccarone Preventive Cardiology Center at The Johns Hopkins University School of Medicine, explained that current guidelines from the U.S. National Institutes of Health emphasize LDL reduction but fail to consider the alternative of raising HDL as the primary or secondary goal, even though each milligram per deciliter increase in HDL reduces the chances of dying from a heart attack risk 3 percent. He announced, "We have reached a turning point in the prevention of coronary heart disease from an emphasis during the last 15 years on lowering LDL cholesterol levels to an emphasis in the next decade on raising levels of HDL cholesterol.”
Following a review of the 50 most significant articles evaluating methods to raise HDL, the authors recommend such lifestyle modifications as regular exercise, smoking cessation, weight control, mild to moderate alcohol intake (for those without liver dysfunction or a history of alcoholism), and diets rich in omega-3 fatty acids with reduced high glycemic carbohydrates.
Niacin (nicotinic acid) is a B vitamin that has been used in high doses (1.0–4.5 grams per day) as a treatment for hyperlipidemia, a condition characterized by elevated blood levels of cholesterol and/or fats as triglycerides (TGs). High concentrations of TGs are associated with increased risk of CHD. Niacin reduces cholesterol and TG levels, and increases the concentration of high-density lipoprotein (HDL) associated with reduced risk of CHD (Crouse 1996). Niacin is usually effective at modulating blood lipids, but side effects sometimes dampen enthusiasm for therapy.
Although side effects are dose-related, few studies have determined an optimal dose of nicotinic acid that alters lipid levels with the fewest side effects. Martin-Jadraque et al. (1996) demonstrated that low-dose nicotinic acid treatment significantly lowered TGs, raised HDL concentrations by approximately 22%, and favorably altered the ratio of total cholesterol to HDL in all subjects. Improvement in blood lipid levels was observed in 75% of subjects who tolerated low-dose nicotinic acid therapy. Although the changes induced by lower doses were less than higher doses, the lower dose was better tolerated. Nicotinic acid may also be useful in combination drug therapy for prevention of CHD if higher doses cannot be tolerated. Use of a lower dose should still be beneficial in for producing a moderate rise in HDL levels.
Long-term treatment with nicotinic acid (4 g/day for 6 weeks) not only corrects serum lipoprotein abnormalities, but also reduces the fibrinogen concentration in plasma and stimulates fibrinolysis (Johansson et al. 1997).
Epidemiologic evidence (Framingham Heart Study) indicates that a low level of HDL is an independent predictor of CHD. Other findings related to low HDL revealed that (1) it is an independent predictor of the number and severity of atherosclerotic coronary arteries, (2) it predicts total mortality in coronary artery disease patients when total cholesterol is in a desirable range (<200 mg/dL), and (3) it is associated with increased restenosis after angioplasty. Study conclusions were that most medications used to treat dyslipidemias will raise HDL levels modestly; however, niacin appears to have the greatest potential to do so, increasing HDL up to 30% (Kwiterovich 1998).
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