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To the Editor: The Clinical Review by Dr Gluckman and colleagues¹ on the management of non–ST-segment elevation acute coronary syndromes suggests considering the addition of niacin to statins if high-density lipoprotein cholesterol levels are less than 40 mg/dL (1.0 mmol/L) or triglyceride levels are greater than 150 mg/dL (1.7 mmol/L). However, niacin can be dangerous and might even increase myocardial ischemia in the acute setting.² This may occur on the basis of coronary steal and/or lowering coronary perfusion pressure due to the vasodilating properties of niacin.

Niacin is an excellent lipid-lowering drug to use alone³ or in combination with a statin⁴ for the prevention of coronary heart disease. However, I believe that if niacin is used, it should never be started during an acute coronary event but should be delayed at least several weeks.

Mark R. Goldstein, MD
markrgoldstein@comcast.net
Cleveland Clinic Florida
Naples

1. Gluckman TJ, Sachdev M, Schulman SP, Blumenthal RS. A simplified approach to the management of non–ST-segment elevation acute coronary syndromes. JAMA. 2005;293:349-357. FREE FULL TEXT 2. Pasternak RC, Kolman BS. Unstable myocardial ischemia after the initiation of niacin therapy. Am J Cardiol. 1991;67:904-906. FULL TEXT | ISI | PUBMED 3. Canner PL, Berge KG, Wenger NK, et al. Fifteen year mortality in Coronary Drug Project patients: long-term benefit with niacin. J Am Coll Cardiol. 1986;8:1245-1255. ABSTRACT 4. Brown BG, Zhao X-Q, Chait A, et al. Simvastatin and niacin, antioxidant vitamins, or the combination for the prevention of coronary disease. N Engl J Med. 2001;345:1583-1592. FREE FULL TEXT

Letters Section Editor: Robert M. Golub, MD, Senior Editor.

JAMA. 2005;293:2092-2093.

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