What are the American Heart Association (AHA) guidelines for managing hypertriglyceridemia with elevated triglyceride levels and low high-density lipoprotein (HDL) cholesterol?

From the Guidelines

The American Heart Association recommends a multifaceted approach for managing hypertriglyceridemia with elevated triglycerides and low HDL cholesterol, prioritizing lifestyle modifications and considering pharmacological therapy based on individual risk factors and triglyceride levels. For a patient with a triglyceride level of 250 mg/dL and HDL of 40 mg/dL, initial treatment should focus on lifestyle modifications, including weight loss, regular physical activity, and dietary changes such as reducing simple carbohydrates, increasing omega-3 fatty acids, and limiting alcohol consumption 1.

Lifestyle Modifications

• Weight loss is considered the most effective lifestyle intervention to lower triglyceride levels, with a 5% to 10% reduction in body weight associated with a 20% decrease in triglycerides 1
• Regular physical activity and dietary changes, such as increasing omega-3 fatty acids and limiting alcohol consumption, are also essential components of lifestyle modifications 1

Pharmacological Management

• For patients with cardiovascular risk factors, statins are typically first-line therapy 1
• For triglyceride levels above 500 mg/dL, fibrates or prescription omega-3 fatty acids may be recommended to reduce pancreatitis risk 1
• Icosapent ethyl, a synthetic n-3 fatty acid preparation, has been shown to reduce ASCVD events by 25% in patients with ASCVD and/or diabetes plus at least one other CVD risk factor, and with triglyceride levels 135–499 mg/dL and LDL-C levels 41–100 mg/dL 1

Monitoring and Follow-up

• Regular lipid panel monitoring is essential, with initial follow-up 4-12 weeks after starting therapy and periodically thereafter 1
• Combination therapy may be necessary for patients not achieving targets with monotherapy, but requires careful monitoring for muscle-related side effects, especially with statin-fibrate combinations 1

From the Research

Management of Hypertriglyceridemia

The American Heart Association guidelines for managing hypertriglyceridemia with elevated triglyceride levels and low high-density lipoprotein (HDL) cholesterol involve a combination of lifestyle modifications and pharmacotherapy.

• For patients with triglyceride levels between 150-499 mg/dL, management starts with dietary changes and physical activity to lower cardiovascular risk 2.
• Lowering carbohydrate intake and increasing fat and protein intake can help lower triglyceride levels 2.
• Moderate- to high-intensity physical activity can also lower triglyceride levels and improve body composition and exercise capacity 2.

Pharmacotherapy

• Statins can be considered for patients with high triglyceride levels who have borderline or intermediate risk of atherosclerotic cardiovascular disease 2.
• For patients at high risk who continue to have high triglyceride levels despite statin use, high-dose icosapent (purified eicosapentaenoic acid) can reduce cardiovascular mortality 2.
• Fibrates, omega-3 fatty acids, or niacin should be considered for patients with severely elevated triglyceride levels to reduce the risk of pancreatitis 2, 3, 4.

Specific Considerations

• For a patient with a triglyceride level of 250 mg/dL and HDL of 40 mg/dL, the primary intervention would involve lifestyle modifications, including changes in diet and exercise 5, 2.
• If lifestyle modifications are not effective, pharmacotherapy with statins or other triglyceride-lowering agents may be considered, depending on the patient's overall cardiovascular risk profile 2, 3, 4.