Effect of niacin or ezetimibe added to chronic statin therapy on carotid intima media thickness: Study

In patients with or at high-risk for coronary artery disease and LDL (bad cholesterol) treated with statins to < 100mg/dL but low HDL (good cholesterol), adding medication to raise HDL was compared with lowering LDL further.

Patients were randomized to the addition of niacin (primarily to raise HDL), or ezetimibe (to further lower LDL cholesterol). Plaque buildup in the lining of the neck arteries was significantly reduced only in the niacin group.

In combination with statins, adding a medication that raises high-density lipoprotein (HDL) cholesterol was more effective in reversing artery wall plaque buildup and in reducing heart disease risk than adding a drug that lowers low-density lipoprotein (LDL) cholesterol, researchers reported today at the American Heart Association Scientific Sessions 2009.

In the study titled The Effect of Extended-release Niacin or Ezetimibe Added to Chronic Statin Therapy On Carotid Intima Media Thickness (ARBITER 6-HALTS), researchers found:

• Adding the cholesterol drug niacin to a statin improved HDL ("good") cholesterol levels and significantly reduced arterial plaque buildup within 8 months, with further improvement seen at the end of the study (14 months).
• A second approach, adding ezetimibe to a statin, lowered LDL ("bad") cholesterol to a greater extent, but did not raise HDL. With it, there was no overall effect on arterial build up in the neck arteries.
• With ezetimibe, greater reductions in LDL cholesterol paradoxically were associated with more arterial buildup, a result opposite to that expected.
• The incidence of major cardiovascular events such as fatal and non-fatal heart attack was higher in the ezetimibe group as compared to the niacin group (5 percent vs. 1 percent).

HDL And LDL Treatment Strategies (HALTS) was a prospective, randomized, parallel group, open-label, blinded endpoint study conducted at Walter Reed Army Medical Center in Washington, D.C., and Washington Adventist Hospital in Tacoma Park, Md. It included 363 adults (80 percent male, average age 68 years) with or at high risk for atherosclerotic cardiovascular disease.

All participants were on cholesterol-lowering statin drugs, and their LDL cholesterol was at the treatment goal of under 100 milligrams per deciliter (mg/dL) of blood. Their HDL cholesterol was lower than 50 mg/dL for men and 55 mg/dL for women.

The researchers randomly assigned the subjects to receive either niacin or ezetimibe in addition to their usual statin. The primary endpoint was the change in the wall thickness of the carotid artery in the neck between the two groups of patients. In June, researchers halted the trial early because the primary endpoint was met. Specifically, 14-month follow-up data on 208 patients showed that in the niacin group, average HDL cholesterol rose from 42 mg/dL to 50 mg/dL and there was a significant regression in artery wall thickness. In the ezetimibe group, average LDL cholesterol levels dropped from 83 mg/dL to 66 mg/dL; however no overall change was found in average artery wall thickness.

LDL cholesterol is generally linked to the buildup of plaque in the arteries, which makes them more likely to become narrowed, and can lead to heart attack or stroke. HDL cholesterol helps clear LDL cholesterol from the blood in a process called reverse cholesterol transport.

"These findings for ezetimibe are counter to the prevailing understanding of LDL cholesterol -- that lowering LDL cholesterol results in slowing of the atherosclerotic process as has been convincingly shown for other classes of lipid modifying drugs, such as statins and bile acid resins," said Allen J. Taylor, M.D. FAHA, principal investigator of the study and director of Advanced Cardiovascular Imaging and the Lipid/Prevention Clinic in the Department of Medicine (Cardiology) at Washington Hospital Center in Washington, D.C.

In earlier studies demonstrating the protective effects of statins, researchers found strong associations between LDL cholesterol reduction and the prevention of cardiovascular disease. Consequently, many people now view LDL cholesterol reduction as a way to measure whether a treatment will be useful.

But HALTS researchers' findings "challenge the use of LDL reduction as a guaranteed surrogate for clinical performance, particularly for new clinical compounds, and in this particular case, ezetimibe," Taylor said. Patients should know their HDL numbers and, if they are low, ask their doctors if adding a treatment such as niacin is right for them once their LDL is treated to goal with a statin drug, he said.

SOURCE American Heart Association