Reducing residual vascular risk in patients with atherogenic dyslipidemia: Where do we go from here?

Residual vascular risk (RvR) represents risk of incident vascular events or progression of established vascular damage persisting on current standards of care. RvR is best captured by cardiovascular risk calculators or the presence of a metabolic syndrome. A substantial proportion of RvR can be reduced by addressing modifiable risk factors, including atherogenic dyslipidemia (AD). The hallmarks of AD are raised triglycerides and decreased levels of HDL-C, driven by VLDL overproduction from insulin resistance/hyperinsulinemia. AD can be targeted by lifestyle intervention, fibrates or nicotinic acid. AD contributes to RvR of micro- and macro-vascular disease in Type 2 diabetes mellitus, even when LDL-C is controlled. The ACCORD Lipid trial demonstrated that macrovascular RvR, high in Type 2 diabetes mellitus, was decreased after the addition of fenofibrate in patients with AD. Fenofibrate also decreased the RvR of retinopathy, irrespective of baseline non-LDL lipids. Ongoing trials will establish whether targeting low HDL-C with niacin reduces RvR in high-risk patients. © 2010 Future Medicine Ltd