Raising HDL cholesterol for cardiovascular disease prevention : is this still feasible?

Plasma high-density lipoprotein cholesterol (HDLC) has received considerable attention as a potential therapeutic target to further reduce cardiovascular risk in the statin era. However, doubts about the clinical benefit achievable with treatments enhancing plasma HDLC levels have been raised by the premature termination of a large phase 3 trial with torcetrapib-the most potent and furthest developed HDLC-raising compound-resulting from excess mortality in patients receiving the drug. The causes of torcetrapib failure are unknown and may be related to the drug's mode of action, off-target toxic effects, or a mixture of both. The failure of torcetrapib does not mean that the concept of targeting HDL in cardiovascular prevention is dead. Other HDLC-raising therapies, which act through disparate molecular mechanisms, are in various stages of preclinical and clinical development. The alternative is the direct administration of synthetic HDL, which has proven activity on atherosclerosis regression in coronary patients.