The Current State of Niacin in Cardiovascular Disease Prevention A Systematic Review and Meta-Regression

Molecular Cardiology Research Institute, Division of Cardiology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts.
Journal of the American College of Cardiology (Impact Factor: 16.5). 12/2012; 61(4). DOI: 10.1016/j.jacc.2012.10.030
Source: PubMed


OBJECTIVES: This study sought to assess the efficacy of niacin for reducing cardiovascular disease (CVD) events, as indicated by the aggregate body of clinical trial evidence including data from the recently published AIM-HIGH (Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health Outcomes) trial. BACKGROUND: Previously available randomized clinical trial data assessing the clinical efficacy of niacin has been challenged by results from AIM-HIGH, which failed to demonstrate a reduction in CVD event incidence in patients with established CVD treated with niacin as an adjunct to intensive simvastatin therapy. METHODS: Clinical trials of niacin, alone or combined with other lipid-altering therapy, were identified via MEDLINE. Odds ratios (ORs) for CVD endpoints were calculated with a random-effects meta-analyses. Meta-regression modeled the relationship of differences in on-treatment high-density lipoprotein cholesterol with the magnitude of effect of niacin on CVD events. RESULTS: Eleven eligible trials including 9,959 subjects were identified. Niacin use was associated with a significant reduction in the composite endpoints of any CVD event (OR: 0.66; 95% confidence interval: 0.49 to 0.89; p = 0.007) and major coronary heart disease event (OR: 0.75; 95% confidence interval: 0.59 to 0.96; p = 0.02). No significant association was observed between niacin therapy and stroke incidence (OR: 0.88; 95% confidence interval: 0.5 to 1.54; p = 0.65). The magnitude of on-treatment high-density lipoprotein cholesterol difference between treatment arms was not significantly associated with the magnitude of the effect of niacin on outcomes. CONCLUSIONS: The consensus perspective derived from available clinical data supports that niacin reduces CVD events and, further, that this may occur through a mechanism not reflected by changes in high-density lipoprotein cholesterol concentration.

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    • ". These changes were associated with reductions in risk of major coronary events by 25% and 20%, respectively, with fibrates and niacin. A more recent meta-analysis of the niacin trials suggested overall benefit from the drug, but the benefit did not correlate with magnitude of change in HDL-C [56]. A meta-analysis of 4 prospective randomized statin IVUS trials revealed that increases in HDL-C independently predicted atheroma regression [57]. "
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    Best Practice & Research: Clinical Endocrinology & Metabolism 06/2014; 28(3):353-368. DOI:10.1016/j.beem.2013.11.002 · 4.60 Impact Factor
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    • "As is well known, niacin has long been employed in the treatment of patients at risk for vascular disease. A recent metaanalysisdadmittedly conducted before release of the HPS2- THRIVE (Heart Protection Study-2 Treatment of HDL to Reduce the Incidence of Vascular Events) trialdhas concluded that niacin therapy reduces risk for cardiovascular events by about one-third; intriguingly, this protection was found to be independent of the extent to which high-density lipoprotein cholesterol (HDL-C) was decreased, suggesting that other factorsdincluding low-density lipoprotein cholesterol (LDL-C) reductiondmay have been primarily responsible for the observed benefit [186]. Indeed, a Mendelian randomization analysis concludes that elevation of plasma HDL-C per se does not reduce risk for myocardial infarction [187]; moreover, a recent meta-regression analysis has found that the extent to which lipid-modifying agents increase HDL-C is not pertinent to their ability to decrease CVD and mortality [188]. "
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