Cited by 2,911Lipoproteins and Cardiovascular HealthCholesterol and Lipid MetabolismDiabetes, Cardiovascular Risks, and Lipoproteins

Niacin in Patients with Low HDL Cholesterol Levels Receiving Intensive Statin Therapy

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The AIM-HIGH Investigators·2011·New England Journal of Medicine

Abstract

BACKGROUND: In patients with established cardiovascular disease, residual cardiovascular risk persists despite the achievement of target low-density lipoprotein (LDL) cholesterol levels with statin therapy. It is unclear whether extended-release niacin added to simvastatin to raise low levels of high-density lipoprotein (HDL) cholesterol is superior to simvastatin alone in reducing such residual risk. METHODS: We randomly assigned eligible patients to receive extended-release niacin, 1500 to 2000 mg per day, or matching placebo. All patients received simvastatin, 40 to 80 mg per day, plus ezetimibe, 10 mg per day, if needed, to maintain an LDL cholesterol level of 40 to 80 mg per deciliter (1.03 to 2.07 mmol per liter). The primary end point was the first event of the composite of death from coronary heart disease, nonfatal myocardial infarction, ischemic stroke, hospitalization for an acute coronary syndrome, or symptom-driven coronary or cerebral revascularization. RESULTS: A total of 3414 patients were randomly assigned to receive niacin (1718) or placebo (1696). The trial was stopped after a mean follow-up period of 3 years owing to a lack of efficacy. At 2 years, niacin therapy had significantly increased the median HDL cholesterol level from 35 mg per deciliter (0.91 mmol per liter) to 42 mg per deciliter (1.08 mmol per liter), lowered the triglyceride level from 164 mg per deciliter (1.85 mmol per liter) to 122 mg per deciliter (1.38 mmol per liter), and lowered the LDL cholesterol level from 74 mg per deciliter (1.91 mmol per liter) to 62 mg per deciliter (1.60 mmol per liter). The primary end point occurred in 282 patients in the niacin group (16.4%) and in 274 patients in the placebo group (16.2%) (hazard ratio, 1.02; 95% confidence interval, 0.87 to 1.21; P=0.79 by the log-rank test). CONCLUSIONS: Among patients with atherosclerotic cardiovascular disease and LDL cholesterol levels of less than 70 mg per deciliter (1.81 mmol per liter), there was no incremental clinical benefit from the addition of niacin to statin therapy during a 36-month follow-up period, despite significant improvements in HDL cholesterol and triglyceride levels. (Funded by the National Heart, Lung, and Blood Institute and Abbott Laboratories; AIM-HIGH ClinicalTrials.gov number, NCT00120289.).

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Crossref · 10.1056/nejmoa1107579

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  • Prior CV outcome studies with niacin or fenofibrate did not prospectively enroll patients with elevated TG levels despite statin therapy.

    “Nonetheless, these studies also did not prospectively enroll patients with elevated TG levels despite statin therapy,6, 12, 13, 14, 15”

    From Rationale and design of <scp>REDUCE‐IT</scp> : Reduction of Cardiovascular Events with Icosapent Ethyl–Intervention Trial (2017) · cites this paper as [15]

    The Study Population section says AIM-HIGH prospectively required elevated triglycerides (150–400 mg/dL) for eligibility. The Lipid Levels section reports that 93.6% of participants were taking a statin at entry, contrary to the claim as applied to this study. Page numbers were not available in our copy. (LLM, conf=0.90)

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  • Post hoc and prespecified subgroup analyses and meta-analyses of five major fibrate trials have shown a cardiovascular benefit in people with moderate dyslipidemia (triglycerides >200 mg/dL and HDL-C <40 mg/dL, either isolated or together) but not in people without dyslipidemia.

    “Post hoc and prespecified subgroup analyses and meta-analyses of 5 major fibrate trialsdHelsinki Heart Study, Veterans Affairs HDL Intervention Trial, Bezafibrate Infarction Project, FIELD, and ACCORD-Lipiddhave shown a CV benefit in persons with moderate dyslipidemia (triglycerides >200 mg/dL and HDL-C <40 mg/dL, either isolated or together) but not in persons without dyslipidemia.”

    From American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. (2022) · cites this paper as [378]

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  • In the EU, treatment with niacin was stopped after the AIM-HIGH and HPS2-THRIVE trials showed no improvement in MACE and an increased occurrence of undesirable side effects.

    “In the EU, treatment with niacin was stopped after the AIM-HIGH and HPS2-THRIVE trials showed no improvement in MACE and an increased occurrence of undesirable side effects [123, 124].”

    From Established and Emerging Lipid-Lowering Drugs for Primary and Secondary Cardiovascular Prevention (2023) · cites this paper as [123]

    The Primary and Secondary End Points section reports no improvement in the composite cardiovascular outcome, and Table 3 reports more study-drug discontinuations with niacin, including for flushing or itching. The Statistical Analysis section says the AIM-HIGH intervention was stopped for lack of efficacy and a higher observed stroke rate, but the Discussion says a causal link to stroke was uncertain. This 2011 paper describes HPS2-THRIVE as ongoing and does not establish that niacin treatment was stopped in the EU. (LLM, conf=0.88)

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  • A previous trial of niacin showed no significant decrease in cardiovascular risk despite a 26% lowering of triglyceride levels.

    “Similarly, a previous trial of niacin 4 and two previous trials of fenofibrate 5,6 showed no significant decrease in cardiovascular risk, although triglyceride levels were lowered by 26%, 29%, and 26%, respectively.”

    From Triglyceride Lowering with Pemafibrate to Reduce Cardiovascular Risk (2022) · cites this paper as [4]

    The Discussion reports no significant reduction in cardiovascular events with extended-release niacin added to intensive statin therapy. However, the Lipid Levels section reports a 28.6% triglyceride decrease at two years in the niacin group, not 26%; Table 2 also gives no 26% decrease at years one or three. Our copy does not provide page numbers for these passages. (LLM, conf=0.90)

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  • With the exception of the FIELD trial, all these trials involved patients who were receiving statins.

    “With the exception of the FIELD trial, all these trials involved patients who were receiving statins.”

    From Triglyceride Lowering with Pemafibrate to Reduce Cardiovascular Risk (2022) · cites this paper as [4]

    The AIM-HIGH paper reports statin use in its own trial: Table 1, reproduced in the Discussion passage, shows baseline use in 94.4% and 92.8% of the two groups. Our copy does not establish that all the other trials referred to by the citing sentence involved patients receiving statins, or that FIELD was the exception. (LLM, conf=0.83)

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Cites

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Research works printed but not linked: 4

  1. [13]13. Nichols GA, Ambegaonkar BM, Sa- zonov V, Brown JP. Frequency of obtain- ing National Cholesterol Education Pro- gram Adult Treatment Panel III goals for all major serum lipoproteins after initia- tion of lipid altering therapy. Am J Cardiol 2009;104:1689-94.
  2. [14]14. The AIM-HIGH Investigators. The role of niacin in raising high-density lipo- protein cholesterol to reduce cardiovascu- lar events in patients with atherosclerotic cardiovascular disease and optimally treat- ed low-density lipoprotein cholesterol: ra- tionale and study design. Am Heart J 2011;161(3):471.e2-477.e2.
  3. [15]15. Idem. The role of niacin in raising high-density lipoprotein cholesterol to re- duce cardiovascular events in patients with atherosclerotic cardiovascular dis- ease and optimally treated low-density li- poprotein cholesterol: baseline character- istics of study participants. Am Heart J 2011;161:538-43.
  4. [22]22. Carlson LA. Nicotinic acid: its me- tabolism and its effects on plasma free fatty acids. In: Metabolic effects of nico- tinic acid and its derivatives -proceed- ings of a workshop held in Films, Switzer- land, 1970. Bern, Switzerland: Hans Huber, 1971:157-65.

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Authors
The AIM-HIGH Investigators
Corresponding author
The AIM-HIGH Investigators
Venue
New England Journal of Medicine
Published
2011-12-15
Volume
365
Issue
24
Pages
2255-2267
ISSN
  • 0028-4793 (ISSN-L)
  • 1533-4406
OpenAlex
W2165605025
Cited by
2,911
References
19
Citations by year
2026: 79 · 2025: 90 · 2024: 138 · 2023: 133 · 2022: 138 · 2021: 165 · 2020: 146 · 2019: 181 · 2018: 208 · 2017: 203 · 2016: 264 · 2015: 302 · 2014: 316 · 2013: 333 · 2012: 192
FWCI
280.19
Type
journal article
Language
en
Open access
Locations
  • New England Journal of Medicine (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • Abbott Laboratories
  • Eli Lilly and Company
  • Pfizer
  • Sanofi
  • Genentech
  • National Heart, Lung, and Blood Institute
Topics
  • Health Sciences › Medicine › Surgery › Lipoproteins and Cardiovascular Health
  • Health Sciences › Medicine › Surgery › Cholesterol and Lipid Metabolism
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
Keywords
nicotinic acid, simvastatin, HDL cholesterol, low HDL cholesterol, residual cardiovascular risk, atherosclerotic cardiovascular disease, extended-release niacin, ezetimibe, LDL cholesterol, triglycerides, major adverse cardiovascular events, cardiovascular risk reduction, statin therapy, coronary artery disease, myocardial infarction, ischemic stroke, acute coronary syndrome, revascularization
MeSH terms
Aged, Hypolipidemic Agents, Cardiovascular Diseases, Brain Ischemia, Drug Therapy, Combination, Female, Humans, Cholesterol, HDL, Cholesterol, LDL, Male, Middle Aged, Muscular Diseases, Niacin, Triglycerides, Proportional Hazards Models, Treatment Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Simvastatin, Atherosclerosis, Kaplan-Meier Estimate, Medication Adherence

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