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Niacin in AIM-HIGH: What implications for the practitioner?

Nov 15, 2011 11:20 EST


The conclusion from the AIM-HIGH trial is relatively straight-forward: niacin for secondary prevention didn't work for any of the patient subgroups in the study. What are the implications of these results for your practice?

To read a summary of the trial and my interpretation, download this slideset.

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Your comments
Niacin in AIM-HIGH: What implications for the practitioner?
# 1 of 4
November 19, 2011 02:21 (EST)
W.E. Feeman,JR,MD
In 2000 I published an analysis of about 2500 angiograms in eight published angiographic regression trials (Journalof Cardiovascular Risk) and I showed that any therapy that brought LDL levels below 80 mg/dl (when indirect method of HDL measurement is used, but 70 mg/dl if direct measurement of HDL is used) resulted in angiographic stabilization/regressionof coronary plaque in 93% of cases--regardless of HDL level and regardless of how much lower LDL was lowered below 80 mg/dl.  Hence the results of AIM HIGH are not surprising to me.  Details available on my free website at www.bolwinggreenstudy.org.
# 2 of 4
November 19, 2011 02:25 (EST)
Scott
# 3 of 4
November 20, 2011 01:26 (EST)
W.E. Feeman,JR,MD

Scott,

     I can't find your comment.  Write me at my e-mail address, available at my website (free) at www.bowlinggreenstudy.org

# 4 of 4
November 21, 2011 09:51 (EST)
D Judelson

Thanks for your excellent analysis. I was disappointed that the study did not report follow up detail of Lp(a) levels in patients thoughout the study, nor did it correlate Lp(a) levels with events. For those of us that follow/treat Lp(a) elevations and feel it is a risk factor for early/aggressive CAD if significantly elevated, the use of niacin products to reduce Lp(a) levels has a special benefit.

Baseline Lp(a) values had a wide range (varied > 100) with a 3.4 nmol/liter higher median in the placebo group at baseline, but I saw no breakout that the groups were evenly distributed by quartile. Outcomes related to Lp(a) level by quartile were not provided, in fact, the values after year 1 were listed as "not analyzed"! Given that the median drop in Lp(a) was  9 nmol/liter on drug (and 2.1 on placebo) at year 1, this value is NOT helpful as quartile values provide better informaton about patients with elevated levels, that is, those that MAY have a benefit/risk with niacin changes in levels.

This study gives us information on patients with CVD who tolerate (mostly) higher dose statin therapy AND niacin products. For those of us treating patients intolerant to statins or with elevated Lp(a) values, it does not provide guidance on the benefits or risks of niacin use. I hope that the authors HAVE the data on Lp(a) levels by quartile and outcome and will share that data at a later time. I am especially interested in outcomes in the higher Lp(a) group as well as changes in Lp(a) values (as a marker for medication compliance.)

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About Dr Seth Bilazarian
Seth Bilazarian MD has been a Clinical and Interventional Cardiologist at Pentucket Medical Associates in Massachusetts since 1993. He is board certified in Internal Medicine, Cardiovascular Medicine, Nuclear Cardiology, Vascular Ultrasound, Interventional Cardiology, and Vascular and Endovascular Medicine.

Dr Bilazarian performs coronary and peripheral interventions at Lahey Clinic and Massachusetts General Hospital. He has been an investigator in the interventional laboratory for new devices including drug-eluting stents, distal protection devices, imaging devices (OCT and InfraRed), and anticoagulant pharmacotherapy.

Dr Bilazarian is an active participant in clinical trials in congestive heart failure, hypertension, coronary disease prevention, prediabetes management, anemia, atrial fibrillation, and anticoagulation/antiplatelet therapies in the outpatient setting. He has authored numerous papers and book chapters in clinical cardiology. He was appointed as a physician advisor to the circulatory device panel of the FDA in 2008.
About this blog
My intent is to create a forum for dialogue on issues pertinent to private practice cardiology around topics such as:

  • Integration of new data and guidelines on inpatient and outpatient practice in clinical and interventional cardiology
  • Practice approaches to the extra clinical issues in dealing with managed care insurers
  • Strategies for navigating the restrictions of pharmacy benefits managers (PBMs) on pharmacologic therapies for our patients
  • Experiences with restrictions on testing and imaging
The video blog (VLOG) will provide an opportunity to share broadly different approaches to the common conundrums we face in caring for patients. My hope is that this forum will provide useful data points for practice outside of tertiary and academic centers and a look inside community hospitals and physician?s practice patterns in the office, starting with mine.