Book Review

Lipids: Current perspectives

N Engl J Med 1997; 336:1395May 8, 1997

Article

Lipids: Current perspectives
Edited by D. John Betteridge. 302 pp. St. Louis, Mosby, 1996. $75. ISBN: 1-85317-231-6

Physicians used to have mixed feelings about the treatment of hyperlipidemia. They knew that high lipid concentrations cause heart disease, but they also knew that the lifestyle changes required to correct hyperlipidemia could be difficult to implement and that the available drugs were of doubtful safety and effectiveness, poorly tolerated, or both.

The arrival of the 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, or statins, has changed all that. Statins lower cholesterol concentrations, the risk of cardiovascular disease, and total mortality rates; they are easy to take; and up until now they have been remarkably free from side effects. However, putting a patient on a lifelong regimen of these expensive drugs is a major decision, and the correct diagnosis and therapy of dyslipidemias have therefore gained importance.

Lipids: Current Perspectives attempts to give some guidance here. It consists of 17 chapters written by a total of 25 authors — some well known, others more junior — who attempt to answer frequently asked questions regarding the origin and treatment of dyslipidemias. Some of the chapters do this quite well. Thus, a lively review of lipoprotein(a) ends by concluding that the balance of the evidence points to an association of elevated lipoprotein(a) concentrations and an increased risk of atherosclerosis and thrombosis, which is particularly relevant in patients with an elevation of low-density lipoproteins (LDL). Treatment consists of anticoagulants and substantial efforts to lower LDL concentrations, with the option of using nicotinic acid to reduce lipoprotein(a). In contrast, the practical recommendations in the chapter on lipids and the hypertensive patient run to six pages, reflecting perhaps a scarcity of simple answers.

Statins have benefited many patients, but they have not solved certain problems that have characterized the lipid field for many years. The dilemma of how to treat lipid abnormalities is illustrated by the status of plasma triglycerides as a risk factor. Several chapters point out the heterogeneity of the hypertriglyceridemic state. The high concentrations of triglycerides in familial hypertriglyceridemia confer no increase in cardiovascular risk. On the other hand, familial combined hyperlipidemia, a hard-to-pin-down syndrome characterized by increased levels of apolipoprotein B, is the commonest lipid abnormality in survivors of myocardial infarction, found in up to 40 percent of patients, and it often presents with elevated triglycerides. The typical patient with hypertriglyceridemia may also have a low concentration of high-density lipoprotein; an excess of atherogenic small, dense LDL particles; hypertension; type II diabetes; or all of the above. Several of these abnormalities may in turn be caused by upper-body obesity and might be corrected if the patient lost weight and took up vigorous exercise. Unfortunately, obesity is highly resistant to treatment. Should we leave it at that and give all obese patients with hyperlipidemia lipid-lowering drugs? That is not an attractive option, not only because of the cost and potential side effects, which plague even the best drugs, but also because this approach fails to treat the hypertension, type II diabetes, joint problems, and other ills due to obesity. Lifestyle modification is hard for an individual patient, but not impossible for a population. A chapter by Mann on lifestyle modifications reviews the major changes in diet composition that have taken place in the United States and northwestern Europe over the past 25 years and their role in decreasing the rates of coronary heart disease. An even larger effort will be needed to combat the epidemic of obesity now sweeping much of the world. It will not be easy, but it makes more sense than treating each of the ensuing symptoms with separate drugs.

Lipids: Current Perspectives does not address these policy issues, but it does provide reviews of and practical guidance on the relevant topics, and its international approach makes it suitable for a wide audience.

Martijn B. Katan, Ph.D.
Wageningen Agricultural University, 6703 HD Wageningen, the Netherlands

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Citing Articles

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   John E. Calfee, Clifford Winston, Randolph Stempski. (2002) Direct‐to‐Consumer Advertising and the Demand for Cholesterol‐Reducing Drugs*. The Journal of Law and Economics 45:s2, 673-690
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2. 2

   John E. Calfee. (2000) The Increasing Necessity for Market-Based Pharmaceutical Prices*. PharmacoEconomics 18:Supplement 1, 47-57
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