Slaying the CVD dragon with steroids

Cardiovascular diseases (CVD) are a big problem worldwide, accounting for 29% of all deaths and over 16 million deaths annually 1. Ischaemic heart disease (IHD) and stroke are by far the most important contributors to total CVD mortality, responsible for 43% (7.2 million) and 33% (5.5 million) of all CVD deaths, respectively. At the heart of IHD and stroke is atherosclerosis, characterised by foamy macrophages, cholesterol crystals, smooth muscle proliferation and endothelial dysfunction 2. The three leading modifiable risk factors for atherosclerosis are hyperlipidaemia, hypertension and tobacco smoking, accounting for 50–75% of total population attributable risk for CVD mortality 3. By targeting and treating these risk factors, tremendous improvements in health outcomes from IHD and stroke have been achieved over the past 30 yrs, largely owing to population-based reductions in blood pressure, cholesterol, saturated fat intake and cigarette smoking. However, recent disappointing results of torcetrapib (which dramatically raised high-density lipoprotein cholesterol) 4, combination therapy with fenofibrate and simvastatin (which reduced low-density lipoprotein cholesterol) 5 and renin–angiotensin system blockers (which reduced blood pressure) 6, 7 for the attenuation of cardiovascular events beyond standard therapy have been sobering; these findings have suggested that we may have reached the limits of risk reduction with these interventions, and raise an urgent call to find novel pathways and targets to further fight the large burden of IHD and stroke worldwide. Unfortunately, there is a dearth of promising compounds in the pipeline and many large pharmaceutical companies, including Pfizer, have abandoned CVD drug development altogether, after a decade of repeated failures 8. The report in this issue of European Respiratory Journal by Otsuki et al. 9, showing that inhaled corticosteroids (ICS) are associated with reduced atherosclerosis in patients with asthma, is welcome news for patients with CVD. In this …