A 64-year-old man is assessed for discharge after being admitted 2 days ago due to non–ST-segment elevation myocardial infarction. He underwent successful percutaneous coronary intervention to the right coronary artery on the day of admission and has since been symptom free. The patient has a history of hypertension and was treated with lisinopril before admission. His father underwent coronary artery bypass grafting at age 65, and his sister has diabetes mellitus. The patient drinks a 6-pack of beer most nights and does not use tobacco or recreational drugs. Weight is 90 kg (198.4 lb) and height is 177.8 cm (5 ft 10 in). BMI is 28.5 kg/m2. Blood pressure is 142/89 mm Hg. Dentition is poor. The lungs are clear to auscultation, and there are no heart murmurs. A faint bruit is heard over the right carotid artery, but there are no periumbilical bruits. Lower extremity pulses are full and there is no peripheral edema. Fasting laboratory results are as follows:
| Lipid panel | |
| Total cholesterol | 306 mg/dL |
| HDL | 40 mg/dL |
| LDL | not calculated |
| Triglycerides | 465 mg/dL |
| Serum chemistry | |
| Sodium | 140 mEq/L |
| Potassium | 3.8 mEq/L |
| Chloride | 100 mEq/L |
| Bicarbonate | 24 mEq/L |
| Blood urea nitrogen | 14 mg/dL |
| Creatinine | 0.8 mg/dL |
| Calcium | 9.2 mg/dL |
| Glucose | 102 mg/dL |
Thyroid function tests are normal. In addition to high-intensity statin therapy, which of the following is the best recommendation for management of this patient's lipid disorder?
Treatment of hypertriglyceridemia | |||
Triglycerides | 150-499 mg/dL | 500-999 mg/dL | ≥1,000 mg/dL |
General |
| ||
Specific |
|
|
|
ASCVD = atherosclerotic cardiovascular disease; Ω-3 acids = omega-3 fatty acids. | |||
This patient has hypertriglyceridemia, which can occur due to an inherited disorder (eg, familial hypertriglyceridemia), acquired conditions (eg, diabetes mellitus, heavy alcohol consumption), or as an adverse effect of medications (eg, beta blockers, corticosteroids). Elevated triglyceride levels (ie, >150 mg/dL) are associated with increased cardiovascular risk, and severely elevated levels (ie, >1,000 mg/dL) can cause pancreatitis.
In patients with mild hypertriglyceridemia (ie, 150-500 mg/dL) who have known or are at high risk for atherosclerotic cardiovascular disease (ASCVD), statins (eg, atorvastatin) are the recommended first-line pharmacologic therapy. Increased exercise and weight loss are also beneficial. In addition, heavy alcohol intake can significantly increase triglyceride levels; therefore, this patient should reduce alcohol intake to no more than 2 drinks a day (1 drink for women).
(Choice A) Reduced intake of high-sugar foods is beneficial in reducing triglyceride levels; however, a diet completely free of carbohydrates is not recommended because it would eliminate fruits and whole grains from the diet.
(Choice B) Niacin is effective in reducing triglyceride levels; however, its use in combination with statins is associated with an increase in adverse effects (eg, gastrointestinal upset) without improving cardiovascular outcomes.
(Choice C) Fibrates (eg, gemfibrozil, fenofibrate) are the most effective pharmacologic therapy for reducing triglyceride levels and are recommended in patients with moderate to severe hypertriglyceridemia (eg, >500 mg/dL). However, due to cardiovascular benefit, statins are the recommended first-line therapy in patients with ASCVD and mild hypertriglyceridemia. Because of increased rates of adverse effects (eg, myopathy) and lack of proven cardiovascular benefit, the addition of a fibrate to a statin is rarely indicated.
(Choice D) Metformin improves insulin sensitivity, reduces serum triglyceride levels, and can promote weight loss; however, it is not indicated in this patient without diabetes.
(Choice F) Vitamin E supplementation has no demonstrated benefit in the management of lipid disorders or cardiovascular disease.
Educational objective:
For patients with mild hypertriglyceridemia (ie, 150-500 mg/dL) who have known or are at high risk for atherosclerotic cardiovascular disease, statins are the first-line pharmacologic therapy. Fibrates reduce the risk of pancreatitis but have not been shown to improve cardiovascular outcomes.