An elevated blood level of triglycerides (TGs), a form of fat, is an independent risk factor for cardiac disease. The national guideline for a fasting TG level is < 150 mg/dL. Levels higher than 200 mg/dL are associated with a substantial increase in risk of heart attack, stroke and death.
With high TGs, your doctor should search for potential secondary contributory causes for TG elevation (e.g. certain medications, thyroid function issues, poorly controlled diabetes).
The first treatment to lower TGs is diet, exercise and optimizing weight. A diet low in not only fats, but also sugars and simple carbohydrates (the white stuff….potatoes, pasta, bread) helps to lower TG levels, and a routine aerobic exercise program also helps lower TG levels.
But, diet and exercise are not always enough. Many patients require medications.
The first-line medications available for patients with high TG levels are statins. While these medications are classically known for their cholesterol-lowering properties, they also work quite well at lowering TGs, and are shown to reduce the risk of heart attack, stroke and other major adverse cardiac events.
Several second-line medications may also need to be considered. One is omega-3 fatty acids – the type of oil found in deep (cold) water fish like salmon, sardines and mackerel. A total of 2,000 mg (2 grams) of DHA + EPA (the key omega-3 fatty acids) daily is recommended, although higher doses can be used (up to 4 grams) to reduce TG levels. In large trials, omega-3 fatty acid supplementation has been shown to independently reduce cardiac risks 1,2 on top of other interventions.
Another medication used to help lower TG levels is a vitamin – niacin. When niacin is taken in large amounts, it acts like a drug, and is used to lower both TG and LDL (bad) cholesterol levels and raise HDL (good) cholesterol levels. Studies with niacin alone have shown that it reduces the risk of heart attack, stroke and death. However, trials studying whether niacin provides added value on top of statin therapy (in terms of reducing the risk of heart attack, stroke and death) are ongoing, and have not been reported yet. Surrogate measures of cardiac risk, like coronary artery imaging (angiography) studies coupled with outcomes (death, MI, stroke or revascularization) have suggested that niacin plus statins do offer greater benefits compared with statin therapy alone3. We often prescribe niacin in combination with statins to help further reduce TG and LDL levels when needed to reach a patient’s lipid goals.
Researchers in a recent trial known as ACCORD studied diabetic patients who were taking a statin and another medication called fenofibric acid (also known as TriCor and Trilipix) to lower their TG levels. Although the patients’ TG levels went down, the study did not establish an overall benefit for those taking the medication. This was especially true among the women in the trial. A subset of men, particularly those with high TG levels (> 220 mg/dL) and very low HDL seemed to experience a decreased risk of cardiovascular disease events, so men with high TG and low HDL levels may benefit from taking this medication4.
These studies clearly show that the way in which a person lowers TG levels makes a difference, and simply lowering TG levels is not always enough to reduce the risk of cardiac events. A global preventive risk reduction effort is always recommended.
You should discuss the risks and benefits of any therapy with your primary care physician, or see a specialist in preventive cardiology to help understand and evaluate your options.
- GISSI PREVENZIONE INVESTIGATORS. Dietary supplementation with n3 polyunsaturated fatty acids and vitamin E after myocardial infarctation: results of the GISSI Prevenzione trial. Lancet 1999; 354:447-455. www.ncbi.nlm.nih.gov/pubmed/10465168
- THIES F, GARRY JM, YAQOOD P, RERKASEM K, WILLIAMS J,SHEARMAN CP. Association of n-3 polyunsaturated fatty acids with stability of atherosclerotic plaques: a randomized controlled trial. Lancet 2003; 361: 477-485. www.ncbi.nlm.nih.gov/pubmed/12583947
- Brown BG, Zhao, XQ, Chait, A, et.al. Simvastatin and Niacin, Antioxidant Vitamins, or the Combination for the Prevention of Coronary Disease. NEJM 2001; Volume 345:1583-1592. content.nejm.org/cgi/content/short/345/22/1583
- The ACCORD Study Group. Effects of Combination Lipid Therapy in Type 2 Diabetes Mellitus. NEJM 2010; 362 (18)1748. content.nejm.org/cgi/content/abstract/362/17/1563
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