Lipid-lowering drugs and heart failure: where do we go after the statin trials?

PURPOSE OF REVIEW: Heart failure is an important cause of disease burden in aging societies. Although HMG-CoA reductase inhibitors (statins) prevent important causative factors for heart failure, myocardial damage and ischemia, the benefits of statins and low-density lipoprotein (LDL) lowering in heart failure patients have been questioned. The role of other types of dyslipidemia [low high-density lipoprotein (HDL), high triglycerides] and their modification has received less attention in heart failure thus far. RECENT FINDINGS: In patients with coronary artery disease (CAD), or at high risk thereof, statin treatment prevents heart failure. Moreover, intensive statin treatment is better than usual doses. However, initiation of even an effective statin in patients with established, and especially advanced, heart failure has not improved prognosis. Statin treatment may, however, reduce complications and, importantly, has not proved to be harmful in randomized trials. Variables related to HDL metabolism are associated with heart failure in several studies, but trial evidence of HDL or triglyceride-modifying therapies is scant. SUMMARY: Whereas statins are important in preventing or postponing heart failure in the first place, their initiation in established heart failure does not improve prognosis. On the contrary, discontinuation of statin treatment is not indicated due to development of heart failure. Combination therapies of both LDL and HDL may offer more effective possibilities for heart failure prevention.