Contradictions in traditional ideas about atherosclerosis and the efficacy of lipid-lowering therapy. Promising directions

The review presents contradictory results from numerous clinical and epidemiological studies, giving reason to doubt the indisputability of ideas about the primary role of low-density lipoprotein (LP) cholesterol in atherogenesis and the efficacy of lipid-lowering therapy. The latter clearly demonstrates the absence of the expected clinical effect in reducing cholesterol levels after surgical correction of lipid metabolism (ileal bypass surgery) or a very modest effect when using drugs devoid of pleiotropic properties. This circumstance finds an explanation in the fact that, according to modern concepts, only modified LP are the molecular substrate of the pathophysiological process at all stages of atherosclerosis development. Native (intact) LP, the concentration of which in the blood does not correlate with the level of modified forms, are not included in the pathogenesis of atherosclerosis. Consequently, the presence of native LP in the blood does not give a true picture of the activity of the atherosclerotic process. Based on the above, in the treatment of atherosclerosis, it should be considered justified not so much to further improve methods of lipid-lowering effects on the body, which do not have a sufficiently reliable evidence base of clinical effect, but to search for means that prevent the generation of atherogenic, modified LP. In this regard, taking into account the important role of systemic inflammation in the pathogenesis of atherosclerosis, the synthesis and clinical use of safe anti-inflammatory drugs, as well as the development and implementation of methods aimed at eliminating the causes of systemic inflammation, should be considered promising.

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