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
What should we do with a high triglyceride, low HDL, but reasonably normal LDL?
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