Treatment of hypertriglyceridemia

Scenario

-       45M with no other cardiovascular risk factor, presented with HDL 0.6, LDL 2.6, triglyceride 4.5; no prior ischaemic heart disease; failed lifestyle modifications

Issue

-       What to do with a high triglyceride, low HDL, but reasonably normal LDL?

 Lovely dessert @ Meredith's 2015. 

Lovely dessert @ Meredith's 2015. 

Clinical points

-       Epidemiology

o   Prevalence of hyperlipiaemia is high. Its incidence is highest in patients with premature coronary artery disease

o   Disturbances in lipoprotein metabolism are often familial, and may include lipoprotein(a) excess, hypertriglyceridemia with hypoalphalipoproteinemia, and combined hyperlipidemia

-       Associated abnormalities

o   Elevated triglyceride; Low HDL; Elevated small, dense LDL particles

o   Atherogenic triglyceride-rich lipoprotein remnants

o   Insulin resistance

o   Increases in coagulability and viscosity

-       Needs to exclude

o   Poorly controlled diabetes

o   Nephrotic syndrome

o   Hypothyroidism

o   Obesity

-       Non-drug therapy

o   Weight loss via hypocaloric diet

o   Aerobic exercise

o   Strict glycemic control in diabetics

o   Other lifestyle interventions for cardiovascular health

-       Drug therapy

o   STATINS!

§  No direct trials of statins at patients with normal LDL but elevated triglycerides

§  However, the cardiovascular event reduction with statins were equally observed in those with high triglyceride levels

o   Targeted HDL/triglyceride drug therapy

§  Fibrates – raises HDL, lowers triglyceride

§  Nicotinic acid – raises HDL

§  BUT, no strong evidence that these medications reduce cardiovascular events

§  Combining these non-statin agents to statins may increase adverse effects

 

In the scenario above

-       Emphasis on lifestyle changes!!!

-       May consider drug therapy if lifestyle changes fail

-       Drug of choice – low dose statin (e.g. Atorvastatin 20mg)

-       May consider further risk stratification with CT coronary angiography (if patient is reluctant to start statin for primary prevention)

 

Author:

Dr Andrew To