Lipids are transported in the circulation packaged in lipoproteins. The clinical relevance of blood lipid levels is that abnormal levels of lipids in certain lipoproteins are linked to an increase risk of atherosclerosis. Atherosclerosis is a cardiovascular disease in which lipids and inflammatory cells accumulate in plaques within the walls of blood vessels. As a result, vessel walls are narrowed and clots may form, impeding blood flow and oxygen delivery and causing tissue injury. Heart disease occurs because the coronary arteries supplying the heart are a major site where atherosclerotic plaques form.
The liver is central to the regulation of cholesterol levels in the body. Not only does it synthesize cholesterol for export to other cells, but it also removes cholesterol from the body by converting it to bile salts and putting it into the bile where it can be eliminated in the feces. Furthermore, the liver synthesizes the various lipoproteins involved in transporting cholesterol and lipids throughout the body. Cholesterol synthesis in hepatocytes is under negative feedback regulation: increased cholesterol in the cell decreases the activity of HMG-CoA reductase, the rate-limiting enzyme in cholesterol synthesis.
Lipoproteins are particles that contain triacylglycerol, phospholipids and cholesterol and amphipathic proteins called apolipoproteins. You can refresh your memory about the structure of lipoproteins by visiting the web page from fall quarter. Lipoproteins can be differentiated on the basis of their density, but also by the types of apolipoproteins they contain. The degree of lipid in a lipoprotein affects its density—the lower the density of a lipoprotein, the more lipid it contains relative to protein. The four major types of lipoproteins are chylomicrons, very low-density lipoprotein (VLDL), low-density lipoprotein (LDL), and high-density lipoprotein (HDL).
The figure below summarizes the fates of lipoproteins produced by the liver. Refer to it as you read about the different lipoproteins.
The link between cholesterol and heart disease was recognized through the study of individuals with familial hypercholesterolemia. Individuals with this disorder have several-fold higher levels of circulating LDL due to a defect in the function of their LDL receptors. Without functioning LDL receptors, LDL is not cleared from the circulation. As well, because cholesterol cannot get into cells efficiently, there is no negative feedback suppression of cholesterol synthesis in the liver.
A lipid profile typically measures the levels of total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. Dyslipidemia is the term that is used if lipid levels are outside the normal range. High levels of LDL cholesterol (the so-called “bad cholesterol”) greatly increase the risk for atherosclerosis because LDL particles contribute to the formation of atherosclerotic plaques. Low HDL levels ("good cholesterol") are an independent risk factor, because reverse cholesterol transport works to prevent plaque formation, or even cause regression of plaques once they have formed. HDL may also have anti-inflammatory properties that help reduce the risk of atherosclerosis. Fasting triglyceride levels are used to estimate the level of VLDL. High levels of triglycerides are also associated with an increased risk for atherosclerosis, although the mechanism is not entirely clear.
The most important drugs for the treatment of dyslipidemia are by
far, the statins. Statins have been shown in multiple clinical
trials to reduce cardiovascular events and mortality.
The drugs below are used to treat dyslipidemia in specific subsets of patients.
CETP stands for cholesterol ester transfer protein. CETP is a plasma protein that causes the transfer of cholesterol esters (and also triacyglycerol) between HDL, LDL, and VLDL. The result is a net transfer of cholesterol esters from HDL particles to atherogenic LDL and VLDL particles. CETP inhibition prevents this transfer and increases levels of cholesterol in HDL; causing HDL particles to be more stable and long-lived. CETP inhibition also increases reverse cholesterol transport, although the effects on reverse cholesterol transport are complex.
Torcetrapib was a CETP inhibitor whose development was halted in 2006 when it was linked to an increase in deaths from heart disease. Subsequent studies have shown that torcetrapib caused an increase in blood pressure by a mechanism that is unrelated to CETP inhibition.
Anacetrapib and evacetrapib are two new CETP inhibitors in development that appear to be safe and do not have the same off-target effect on blood pressure shown by torcetrapib. Both of these drugs have shown promising results in recent clinical trials.