II. Pathophysiology
- Triglycerides are a major component of serum VLDL
- Independent risk factor for Coronary Artery Disease
- Triglycerides >500: Increases premature CAD risk by 11.4 fold
- Triglycerides >300 and HDL<30: Increases premature CAD risk by 17.2 fold
- Type III Dyslipidemia: Increases premature CAD risk by 5-10 fold
- (2005) JACC 45:1003-12 [PubMed]
III. Causes
IV. Labs
- Lipid Panel
-
Serum Triglycerides
- Normal: <150 mg/dl
- High: 150 to 499 mg/dl
- Severe: >=500 mg/dl
- Serum Glucose
V. Management
-
General therapeutic lifestyle changes
- Reduce body weight by at least 5-10%
- Weight decrease alone may decrease Serum Triglycerides by 20%
- Increase aerobic Exercise (esp. higher intensity) and Resistance Training
- Walking 3-4 miles in approximately 40 minutes daily normalizes Triglycerides within 1 week
- Limit Simple Sugars and simple Carbohydrate intake and focus on lower Glycemic Foods
- Replace simple Carbohydrates with Protein and monunsaturated fats
- Increase monounsaturated fat intake (e.g. Mediterranean Diet)
- Optimize Blood Sugar control in Diabetes Mellitus
- Consider Metabolic Syndrome management
- Reduce body weight by at least 5-10%
-
Serum Triglycerides 150 to 199 mg/dl (Borderline high)
- Therepeutic lifestyle changes above
- Lower LDL Cholesterol to goal (see Hyperlipidemia)
-
Serum Triglycerides 200 to 499 (high)
- Therepeutic lifestyle changes above
- Primary goal: Lower LDL Cholesterol
- Statin AntiHyperlipidemics for high Cardiovascular Risk
- Statins also lower Serum Triglycerides 10-30%
- Statin AntiHyperlipidemics for high Cardiovascular Risk
- Secondary goal: Lower Triglycerides
- Omega 3 Fatty Acids
- Fish oil 2-4 g EPA/DHA daily
- Omega 3 Fatty Acids
- Other agents that have been previously recommended (but fallen out of favor, lack of efficacy, side effects)
-
Serum Triglycerides >500 (very high)
- Therepeutic lifestyle changes above
- Primary goal is to lower Triglycerides
- First-line
- Statins
- Lower Triglycerides 10-30%
- Statins
- Second-Line
- Omega 3 Fatty Acids
- Fish oil 2-4 g EPA/DHA daily or
- Vascepa 2 g orally twice daily
- Omega 3 Fatty Acids
- Other agents that have been previously recommended (but fallen out of favor, lack of efficacy, side effects)
- Fibrate (Tricor, Gemfibrozil) decreases triglcerides by 25-50%
- Niacin with or without Fibrate
- Niacin lowers Serum Triglycerides by 10-35% (but does not alter cardiovascular outcomes)
- First-line
- Secondary goal is to lower LDL Cholesterol
-
Serum Triglycerides >1000 (highest)
- Aggressive weight loss and Diabetes Mellitus control
- High level of suspicion for secondary cause
- Management as for Serum Triglycerides >500 mg/dl
- Manage Acute Pancreatitis
- Early and aggressive Serum Triglyceride lowering is associated with better outcomes
- Insulin Infusion 0.25 units/kg/h with dextrose infusion unless hyperglycemic OR
- Plasmapheresis if Insulin Infusion is not effective
VI. Complications
-
Cardiac Risk Factor
- Independent risk factor for cardiovascular disease (beyond standard major CAD risk factors)
- Associated with Metabolic Syndrome and Diabetes Mellitus, which are also signirficant CAD risks
-
Pancreatitis
- Increased risk at Serum Triglycerides >500 mg/dl
-
Acute Pancreatitis is typically associated with Serum Triglycerides >1000 mg/dl
- Responsible for 2-4% of Pancreatitis cases
- Consider acute Serum Triglyceride lowering with Insulin Infusion, Plasmapheresis