Hypertriglyceridemia: A Guide to Assessment and Treatment

Hospital Physician September 2008 17 T he National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) guidelines recommend that a fasting lipid profile be obtained and repeated every 5 years in all adults beginning at age 20 years.1 Based on these guidelines, hypertriglyceridemia is defined as a fasting plasma triglyceride level that exceeds 200 mg/dL and can be further classified as borderline-high (150− 199 mg/dL), high (200−499 mg/dL), and very high (≥ 500 mg/dL).1 When triglyceride levels exceed 500 mg/dL, patients may develop acute pancreatitis. Levels exceeding 1000 mg/dL define chylomicronemia, which may result in lipemia retinalis, eruptive xanthomas, hepatomegaly, and potentially fatal acute pancreatitis. In the United States, the 90th percentile for triglyceride levels historically has been estimated at approximately 250 mg/dL,2 100 mg/dL above the currently recommended target. Hypertriglyceridemia is associated with an increased risk for coronary artery disease (CAD) and can be a marker for other lipid and nonlipid cardiovascular risk factors (ie, small low-density lipoprotein [LDL] particles, low high-density lipoprotein [HDL] cholesterol, hypertension, insulin resistance). Overweight/obesity and insulin resistance have been found to be associated with elevated triglyceride levels, and hypertriglyceridemia is a component of the metabolic syndrome.3,4 Given the rising incidence of diseases associated with overweight/obesity and insulin resistance, including the metabolic syndrome and diabetes mellitus,5−7 identification and treatment of hypertriglyceridemia is becoming increasingly important. Hypertriglyceridemia is often clinically silent and is typically detected by lipid screening in asymptomatic patients. Treatment of hypertriglyceridemia should be individualized based on triglyceride level, family history of CAD, presence of CAD risk factors (eg, smoking, hypertension, HDL cholesterol levels < 40 mg/dL), and age. This article reviews the pathogenesis, classification, clinical evaluation, and rationale for treatment of hypertriglyceridemia. Treatment recommendations are outlined based on severity of triglyceride elevations. paThogenesis