[LDL-apheresis in the treatment of coronary heart disease. Rationale for a specific adjuvant therapy].

Coronary artery disease (CHD) still remains the leading cause of death in all industrialized countries. In Germany, it claims the lives of an estimated 220,000 men and women and causes 200,000 non-lethal AMI's each year. Inspite of great efforts in the last 30 years, 25% of men and 40% of women still die within 12 months after they preliminary survived their first myocardial infarction. The total direct plus indirect expenses for CHD in the year 2000 sum up to approximately 57 billion Euro in Germany and to 100 billion US $ in the US. To date, management of coronary artery disease still consists mainly of a therapy designed to improve blood flow and oxygen supply to the heart or to reduce myocardial oxygen consumption. On this line angioplasty, bypass surgery, and more recently stenting of coronary arteries, have become leading techniques, but only a minority (<50%) of patients at risk for CHD received therapy to change the atherosclerotic process itself. However, only by means of a causal intervention with the pathmaker mechanism of atherosclerosis can we expect to decrease the financial burden of CHD. No question, one of the leading causal factors for early atherosclerosis and coronary heart disease is the abundance of LDL cholesterol in the blood, exceeding limits of 100 mg/dl. Thus, recommendations for therapy focus on LDL levels less than 100 mg/dl. With the introduction of the statins-a family of very potent lipid lowering agents-such target levels can be achieved in most patients, resulting in a drastic decrease of LDL concentrations, as well as in a reduction of cardiac and total mortality. There is, however, a remaining small group of patients, who are more or less resistant to an adequate combination of dietary and drug therapy. For these patients, various techniques of apheresis have been available for over 15 years. Some of them, e. g., H.E.L.P. System, KANEKA System, have been approved by the FDA in the US and comparable regulatory offices in Europe. The most extensive experimental and clinical experience was gathered with the H.E.L.P. System by B. Braun Melsungen, which differs from other apheresis techniques by its efficiency to eliminate LDL, Lp(a), fibrinogen and CRP simultaneously. The clinical results obtained to date with the H.E.L.P.-LDL-apheresis clearly demonstrate a significant reduction of risk factors and clinical events, as well as an excellent long-term tolerance. A comprehensive literature survey on H.E.L.P. is part of this communication.