What is the best approach to manage hypertriglyceridemia in a 56-year-old male with a recent myocardial infarction (MI) status post percutaneous coronary intervention (PCI) on atorvastatin (lipitor) 80 mg?

From the Guidelines

For a 56-year-old male with recent MI post-PCI who is already on high-intensity atorvastatin 80 mg but has hypertriglyceridemia, the best approach would be to add icosapent ethyl (Vascepa) 2 grams twice daily, as it has demonstrated cardiovascular benefit in patients with established cardiovascular disease and elevated triglycerides 1.

Key Considerations

• Before adding medication, lifestyle modifications should be emphasized, including:
  • Limiting alcohol
  • Reducing simple carbohydrates and sugars
  • Increasing physical activity
  • Achieving weight loss if needed
• If triglycerides remain severely elevated (>500 mg/dL) despite these measures, fenofibrate 145 mg daily could be considered, though with caution due to potential muscle-related side effects when combined with high-dose statins 1.
• Regular monitoring of liver enzymes, creatine kinase, and lipid panels is essential.

Rationale

The rationale for this approach is that while statins primarily lower LDL cholesterol, they have limited effect on triglycerides, and icosapent ethyl specifically targets triglyceride reduction while providing additional cardiovascular protection in this high-risk post-MI patient 1.

Additional Guidance

• Patients with very high triglycerides should not consume alcohol, and the use of bile acid sequestrants is relatively contraindicated when triglycerides are greater than 200 mg per dL 1.
• The combination of high-dose statin plus fibrate can increase risk for severe myopathy, and statin doses should be kept relatively low with this combination 1.

From the FDA Drug Label

Atorvastatin calcium reduces total-C, LDL-C, apo B, and TG, and increases HDL-C in patients with hyperlipidemia (heterozygous familial and nonfamilial) and mixed dyslipidemia In two multicenter, placebo-controlled, dose-response trials in patients with hyperlipidemia, atorvastatin calcium given as a single dose over 6 weeks, significantly reduced total-C, LDL-C, apo B, and TG.

The patient is already on atorvastatin 80 mg, which is the maximum dose.

• Maximal dose already achieved: The patient is on the highest approved dose of atorvastatin (80 mg), and the label does not provide guidance on how to manage hypertriglyceridemia in this scenario.
• No clear guidance: The label does not provide specific recommendations for managing hypertriglyceridemia in patients with triglyceride levels of 8.43 mmol/L on maximal atorvastatin therapy.
• Consider additional treatments: Based on the information provided, it is unclear what the best approach would be, and the label does not provide direct guidance on this specific scenario 2.

From the Research

Management of Hypertriglyceridemia

The patient in question has a recent myocardial infarction (MI) status post percutaneous coronary intervention (PCI) and is on atorvastatin 80 mg with triglycerides of 8.43 mmol/L. To manage hypertriglyceridemia in this patient, consider the following:

• The patient's triglyceride level is elevated, which is a risk factor for cardiovascular disease (CVD) and pancreatitis 3, 4.
• Statins, such as atorvastatin, are the first line of therapy for managing mild to moderate hypertriglyceridemia, but may not be sufficient to reduce triglyceride levels in all patients 3.
• Additional therapies, such as fibrates, niacin, or long-chain omega-3 fatty acids, may be necessary to further reduce triglyceride levels and residual CVD risk 3, 4.

Treatment Options

Consider the following treatment options for this patient:

• Adding a fibrate, such as fenofibrate, to the patient's current atorvastatin therapy, as combination therapy with a statin and fibrate has been shown to be effective in reducing triglyceride levels 5, 6, 7.
• Using long-chain omega-3 fatty acids as an adjunct to statin therapy, which may be a well-tolerated and effective alternative to fibrates and niacin 3.
• Considering the patient's recent MI and PCI, it is essential to weigh the benefits and risks of adding additional therapies to their current regimen.

Key Considerations

When managing hypertriglyceridemia in this patient, keep in mind:

• The patient's 10-year risk of atherosclerotic cardiovascular disease should be calculated to determine the role of medications 4.
• High-dose icosapent (purified eicosapentaenoic acid) may be considered for patients at high risk who continue to have high triglyceride levels despite statin use 4.
• The addition of fibrates, omega-3 fatty acids, or niacin should be considered for patients with severely elevated triglyceride levels to reduce the risk of pancreatitis 4.