Hypertriglyceridemia: A strategic approach
This review, and the at-a-glance tables that follow, detail indications and strategies for the treatment of adults with hypertriglyceridemia.
PRACTICE RECOMMENDATIONS
› Evaluate patients for hypertriglyceridemia when they have a comorbid condition (eg, type 2 diabetes, obesity, hypothyroidism, metabolic syndrome, alcoholism). B
› Do not require fasting status when evaluating triglycerides in a lipid panel. B
› Make therapeutic lifestyle changes first-line treatment for hypertriglyceridemia. C
› Prescribe fibrates for severe hypertriglyceridemia to reduce the risk and recurrence of pancreatitis. A
› Prescribe a statin and an omega-3 fatty acid (fish oil) to lower the triglyceride level and thus reduce resulting atherogenicity when the risk of atherosclerotic cardiovascular disease is > 7.5%. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
An ASCVD risk–HTG connection? In the population already at higher risk of ASCVD (> 7.5%), HTG is recognized as a risk-enhancing factor because of its atherogenic potential (Table 22); however, there is insufficient evidence that TGs have a role as an independent risk factor for ASCVD. In a population-based study of 58,000 people, 40 to 65 years of age, conducted at Copenhagen [Denmark] University Hospital, investigators found that those who did not meet criteria for statin treatment and who had a TG level > 264 mg/dL had a 10-year risk of a major adverse cardiovascular event similar to that of people who did meet criteria for statin therapy.15
The FIELD (Fenofibrate Intervention and Event Lowering in Diabetes) and AIM-HIGH (Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides and Impact on Global Health Outcomes) studies, among others, have failed to show a significant reduction in coronary events by treating HTG.10
That said, it’s worth considering the findings of other trials:
- In the PROVE IT-TIMI 22 (Pravastatin or Atorvastatin Evaluation and Infection Therapy–Thrombolysis in Myocardial Infarction 22) trial, an overall 28% reduction in endpoint events (myocardial infarction, acute coronary syndrome) was seen with high-intensity statin therapy, compared to moderate-intensity therapy.10 However, there was a sizeable residual risk identified that was theorized by investigators to be associated with high non-HDL lipoproteins, including TGs.
- A 2016 study in Israel, in which 22 years of data on 15,355 patients with established ASCVD were studied, revealed that elevated TGs are associated with an increased long-term mortality risk that is independent of the HDL level.16
- A cross-sectional study, nested in the prospective Copenhagen City Heart Study, demonstrated that HTG is associated with an increase in ischemic stroke events.17
Treatment
Therapeutic lifestyle changes
Changes in lifestyle are the foundation of management of, and recommended first-line treatment for, all patients with HTG. Patients with a moderately elevated TG level (175-499 mg/dL, measured in a fasting or nonfasting state) can be treated with therapeutic lifestyle changes alone1,2; a trial of 3 to 6 months (see specific interventions below) is recommended before considering adding medications.10
Weight loss. There is a strong association between BMI > 30 and HTG. Visceral adiposity is a much more significant risk than subcutaneous adipose tissue. Although weight loss to an ideal range is recommended, even a 10% to 15% reduction in an obese patient can reduce the TG level by 20%. A combination of moderate-intensity exercise and healthy eating habits appears to assist best with this intervention.18
Continue to: Exercise
