LDL-cholesterol, HDL-cholesterol or triglycerides--which is the culprit?

Dyslipidaemia in patients with type 2 diabetes commonly consists of elevated triglyceride levels; normal or slightly elevated low-density lipoprotein (LDL)-cholesterol levels with a preponderance of small, dense LDL particles; and low high-density lipoprotein (HDL)-cholesterol levels with a preponderance of small, dense HDL. These abnormalities are closely connected, with prolonged residence of high levels of triglyceride-rich particles in the circulation favoring abnormalities in LDL and HDL. Each of these factors has been associated with endothelial dysfunction; each contributes directly or indirectly to atheroma formation, with small, dense LDL and triglyceride-rich remnants increasing deposition of cholesteryl ester in vessel walls. This process is facilitated by reduced reverse cholesterol transport in association with low levels of HDL-cholesterol and abnormal HDL. Lipid-lowering therapy focused on LDL-cholesterol reduction is highly successful in preventing coronary disease in diabetic patients. Additional strategies for treating the cluster of risk factors in dyslipidaemia are necessary to further reduce atherosclerotic disease in this population.