What are the ECS (European Cardiology Society) 2025 guidelines for managing hypertriglyceridemia?

ECS 2025 Guidelines for Hypertriglyceridemia Management

The European Cardiology Society 2025 guidelines recommend a stratified approach to hypertriglyceridemia management based on triglyceride levels, with lifestyle modifications as the cornerstone of treatment for all patients and specific pharmacological interventions reserved for those with severe hypertriglyceridemia or elevated cardiovascular risk. 1

Classification of Hypertriglyceridemia

• Normal triglycerides: <150 mg/dL
• Mild to moderate hypertriglyceridemia: 150-499 mg/dL
• Severe hypertriglyceridemia: 500-999 mg/dL
• Very severe hypertriglyceridemia: ≥1000 mg/dL

Management Algorithm Based on Triglyceride Levels

For Severe Hypertriglyceridemia (≥500 mg/dL)

1. Immediate evaluation for secondary causes of hypertriglyceridemia and implementation of medical therapy to reduce pancreatitis risk 2
2. First-line pharmacological treatment:
   • Fibrates (fenofibrate 54-160 mg daily) 3
   • Dosage should be individualized according to patient response with adjustments following lipid determinations at 4-8 week intervals
   • Maximum dose: 160 mg once daily 3
3. Second-line options:
   • Prescription omega-3 fatty acids (4 g/day) 4
   • Icosapent ethyl 2 g twice daily with food 4

For Mild to Moderate Hypertriglyceridemia (150-499 mg/dL)

1. Address and treat:
   • Lifestyle factors (obesity and metabolic syndrome)
   • Secondary factors (diabetes, chronic liver or kidney disease, nephrotic syndrome, hypothyroidism)
   • Medications that raise triglycerides 2
2. For patients with ASCVD or cardiovascular risk factors on a statin with controlled LDL cholesterol but elevated triglycerides (135-499 mg/dL), consider adding icosapent ethyl to reduce cardiovascular risk 2, 4

Lifestyle Modifications (Essential for All Patients)

• Dietary changes:
  • Reduce total fat intake to 20-25% of total calories
  • Increase soluble fiber (>10g/day)
  • Include 2+ servings of fatty fish weekly
  • Limit added sugars to <5% of calories 1
• Weight management: Target 5-10% weight loss if overweight/obese (can lower triglycerides by ~20%) 1
• Physical activity: At least 150 minutes/week of moderate-intensity aerobic activity 1
• Alcohol reduction: Complete abstinence recommended, especially for those with severe hypertriglyceridemia 2, 1

Monitoring and Follow-up

• Monitor triglyceride levels every 4-8 weeks until stabilized, then every 3 months
• Target triglyceride level of <500 mg/dL to reduce pancreatitis risk 1
• When using fenofibrate, evaluate renal function before initiation, within 3 months after starting, and every 6 months thereafter 1, 3

Special Considerations

• Combination therapy: When using fibrates with statins, fenofibrate is preferred over gemfibrozil due to lower risk of myopathy 1
• Renal impairment: For patients with mild to moderate renal impairment, start fenofibrate at 54 mg/day and increase only after evaluating effects on renal function and lipid levels 3
• Acute pancreatitis risk: For triglycerides >1000 mg/dL, aggressive intervention is warranted to prevent acute pancreatitis, including consideration of IV insulin therapy or plasmapheresis in acute settings 1

Important Warnings

• Medication interactions: Monitor patients receiving omega-3 fatty acids and concomitant anticoagulants/antiplatelet agents for bleeding risk 4
• Adverse reactions: Be aware of potential side effects including musculoskeletal pain, peripheral edema, constipation, gout, and atrial fibrillation with icosapent ethyl 4
• Contraindications: Fenofibrate is contraindicated in patients with severe renal impairment, active liver disease, preexisting gallbladder disease, and nursing mothers 3

By following this structured approach based on triglyceride levels and cardiovascular risk, clinicians can effectively manage hypertriglyceridemia while reducing the risk of pancreatitis and cardiovascular events.