Risk Assessment and Guidelines for the Management of High Triglycerides

Cardiovascular disease (CVD) remains a major cause of mortality in the Western world. In spite of the reduction of CVD risk by the use of lipid lowering agents per current treatment goals, there remains substantial residual and absolute risk of CVD in high risk populations. Focus on elevated triglyceride (TG) levels deserves renewed attention, particularly as one-third of all adults in the United States suffer from elevated TG and a growing number of people are diagnosed with the metabolic syndrome or type 2 diabetes mellitus (T2DM). The dyslipidemia of metabolic syndrome and T2DM is characterized by raised TG concentrations, low high density lipoprotein (HDL-c) concentrations and marked elevation in triglyceride rich lipoproteins (TRL). This triad is now known as atherogenic dyslipidemia. In addition small dense LDL and small HDL are frequently observed. There has been growing data that points towards an association of fasting and non-fasting triglycerides with CVD. However, the association of TG as an independent risk faster in CVD is confounded by its inverse metabolic relationship with high density lipoprotein (HDL-c) and the heterogeneity of TG lipoproteins. Current guidelines suggest diagnosis of hypertriglyceridemia based on fasting levels where length of fast is recommended to be 9-12 hours. Although non-fasting TG levels may be a better indicator of risk, the lack of standardization of non-fasting TG measurements, lack of specific reference ranges, and the variability of postprandial lipid measurements have hampered their routine clinical use. Current guidelines focus mainly on LDL-c levels; however, lowering TG may provide additional benefit for CVD prevention. Lifestyle changes including dietary changes and exercise play an important role in the treatment of hyperlipidemia. Pharmacological agents used in the treatment of hypertriglyceridemia include niacin, fibrates, fish oil, and statins. Most guidelines recommend treating elevated TG for prevention of pancreatitis. This article will discuss the role of elevated TG in pancreatitis and CVD risk. For complete coverage of this and related topics, please visit www.endotext.org.