Overview on LDL‐apheresis in cardiovascular diseases

Abstract

LDL apheresis has been widely accepted as an effective treatment for hypercholesterolemic patients who are resistant to drug and conventional therapy such as in case of familial hypercholesterolemia (FH). There are various techniques for performing LDL apheresis including heparin‐induced extracorporeal LDL precipitation (HELP), specific immunoadsorption, double membrane filtration, dextran sulphate adsorption (Liposorber), and direct adsorption of lipoproteins (DALI, Liposorber D). All these techniques remove atherogenic substances such as LDL and Lp(a) at a high rate, however, the degree of HDL removal is low. Homozygous FH is regarded as an absolute indication of LDL apheresis, and the administration of repeat LDL apheresis has been shown to allow long‐term survival by preventing cardiac events and retarding the progression of aortic stenosis. In heterozygous FH, angiographic trials revealed that the combination of LDL apheresis and drug therapy delayed the progression and induced a regression of coronary atherosclerosis (LARS, HELP Study, and L – CAPS). The clinical effects of LDL apheresis such as improvements in endothelial dysfunction, the coronary flow reserve, hemorheological factors together with decreases in oxidized LDL, hsCRP, and adhesion molecule have been reported. Furthermore, LDL apheresis increases HGF which has an angiogenic effect. The clinical efficacy produced by LDL apheresis is therefore able to prevent cardiovascular events. A Hokuriku study evaluated 130 Hetero FH patients and divided them into 2 groups; namely, the LDL apheresis treated patients and those receiving drug therapy. The study followed up these patients for 6 years. The findings showed LDL apheresis to reduce the number of cardiovascular events by (72%) in the LDL apheresis group. The regression of coronary plaque has also been reported (LACMART) using intracoronary ultrasound. Recent developments in non invasive vascular imaging technology, such as multi detector‐row CT, now enable us to evaluate the clinical effects of LDL apheresis in patients with cardiovascular disease. Recently, due to the advent of potent statins, the clinical use of LDL apheresis is liable to decrease. On the other hand, the clinical use of apheresis (rheopheresis) for peripheral artery occlusive disease is increasing. Beside these diseases, effectiveness of LDL apheresis for carotid atherosclerosis, cholesterol embolic disease, the prevention of restenosis in post PCI cases, post transplant donor vessel disease, cerebrovascular disorders, and nephrotic syndrome have also recognized. The efficacy of LDL apheresis for cardiovascular diseases is remarkable and therefore to promote the application of LDL apheresis as a treatment of intractable cardiovascular diseases, we need to reduce the present high cost of the treatment and more clearly elucidate its clinical effectiveness.