High-density lipoprotein cholesterol (HDL-C) concentration is a strong predictor of
cardiovascular events in both naïve and statin-treated patients. Nicotinic acid is
an attractive option for decreasing residual risk in statin-treated or statin-intolerant
patients since it increases HDL-C by up to 20% and decreases low-density lipoprotein
cholesterol and lipoprotein(a) plasma concentrations.
We performed a computerized PubMed literature search that focused on clinical trials
evaluating niacin, alone or in combination with other lipid-lowering drugs, published
between January 1966 and August 2008.
Among 587 citations, 29 full articles were read and 14 were eligible for inclusion.
Overall 11 randomized controlled trials enrolled 2682 patients in the active group
and 3934 in the control group. In primary analysis, niacin significantly reduced major
coronary events (relative odds reduction=25%, 95% CI 13, 35), stroke (26%, 95% CI=8,
41) and any cardiovascular events (27%, 95% CI=15, 37). Except for stroke, the pooled
between-group difference remained significant in sensitivity analysis excluding the
largest trial. In comparison with the non-niacin group, more patients in the niacin
group had regression of coronary atherosclerosis (relative increase=92%, 95% CI=39,
67) whereas the rate of patients with progression decreased by 41%, 95% CI=25, 53.
Similar effects of niacin were found on carotid intima thickness with a weighted mean
difference in annual change of -17 microm/year (95% CI=-22, -12).
Although the studies were conducted before statin therapy become standard care, and
mostly in patients in secondary prevention, with various dosages of nicotinic acid
1-3g/day, this meta-analysis found positive effects of niacin alone or in combination
on all cardiovascular events and on atherosclerosis evolution.
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