From the Guidelines
For a patient with coronary artery disease and persistently elevated triglycerides of 392 mg/dL despite maximum statin therapy, I recommend adding a fibrate such as fenofibrate (145 mg daily) or gemfibrozil (600 mg twice daily), though gemfibrozil should be used cautiously with statins due to interaction risks, as suggested by the 2001 guidelines 1. Alternatively, prescription omega-3 fatty acids like icosapent ethyl (Vascepa, 2 grams twice daily) or omega-3 acid ethyl esters (Lovaza, 4 grams daily) can be added, as supported by the 2013 guidelines 1. However, it's essential to note that the most recent guidelines from 2023 1 do not recommend the use of nonprescription or dietary supplements, including fish oil and omega-3 fatty acids, for patients with coronary artery disease, given the lack of benefit in reducing cardiovascular events. Therefore, the use of prescription omega-3 fatty acids should be considered with caution and under the guidance of a healthcare professional. Lifestyle modifications remain essential, including:
- A low-carbohydrate diet (especially limiting simple sugars and refined carbohydrates)
- Alcohol restriction
- Regular exercise For patients with diabetes, optimizing glycemic control is crucial as hyperglycemia drives triglyceride production. The goal is to reduce triglycerides below 150 mg/dL to decrease pancreatitis risk and potentially improve cardiovascular outcomes, as elevated triglycerides contribute to atherosclerosis through increased small dense LDL particles and inflammatory processes. It's also important to consider the recommendations from the 2007 European guidelines 1, which suggest that statin treatment should be initiated early in patients with acute coronary syndrome, and that lifestyle changes, including dietary intervention, should be combined with effective drug treatment. Overall, the management of elevated triglycerides in patients with coronary artery disease requires a comprehensive approach that includes pharmacological therapy, lifestyle modifications, and careful consideration of the latest clinical guidelines.
From the FDA Drug Label
The Coronary Drug Project, completed in 1975, was designed to assess the safety and efficacy of niacin and other lipid-altering drugs in men 30 to 64 years old with a history of MI Over an observation period of 5 years, niacin treatment was associated with a statistically significant reduction in nonfatal, recurrent MI. In a double-blind, multi-center, forced dose-escalation study, monthly 500 mg increases in niacin extended-release dose resulted in incremental reductions of approximately 5% in LDL-C and Apo B levels in the daily dose range of 500 mg through 2000 mg (Table 4). Pooled results for major lipids from these three placebo-controlled studies are shown below (Table 5). Table 5 Selected Lipid Response to Niacin Extended-Release in Placebo-Controlled Clinical Studies* Mean Baseline and Median Percent Change from Baseline (25th, 75th Percentiles) Niacin Extended-ReleaseDose n LDL-C HDL-C TG 1000 mg at bedtime 104 Baseline (mg/dL) 218 45 172 Percent Change -7 (-15,0) +14 (+7, +23) -16 (-34, +3) 1500 mg at bedtime 120 Baseline (mg/dL) 212 46 171 Percent Change -13 (-21, -4) +19 (+9, +31) -25 (-45, -2) 2000 mg at bedtime 85 Baseline (mg/dL) 220 44 160 Percent Change -16 (-26, -7) +22 (+15, +34) -38 (-52, -14)
Treatment of Triglyceride Level of 392 Despite Max Statin in Patient with Coronary Artery Disease
- The patient has a high triglyceride level of 392 despite being on maximum statin therapy.
- Niacin Extended-Release may be considered as an adjunctive therapy to further reduce triglyceride levels and improve lipid profiles.
- According to the study, niacin extended-release at a dose of 2000 mg/day can reduce triglyceride levels by approximately 38% and increase HDL-C levels by 22% (2).
- However, it is essential to note that the patient's renal function and other comorbidities should be carefully evaluated before initiating niacin therapy, as it may increase the risk of renal impairment and other adverse effects.
- Fenofibrate may also be considered as an alternative therapy, but its efficacy in reducing triglyceride levels in patients with coronary artery disease is not as well established as niacin (3).
From the Research
Treatment Options for High Triglyceride Levels
- Despite being on maximum statin therapy, patients with coronary artery disease and high triglyceride levels (such as 392) may require additional treatment to reduce their cardiovascular risk 4.
- Potential pharmacologic therapies for hypertriglyceridemia include fibrates, niacin, omega-3 fatty acids, and antidiabetic drugs, in addition to lifestyle modification 4.
- The use of prescription omega-3 fatty acids has been shown to be effective in reducing triglyceride levels, particularly when used in combination with fenofibrate 5.
Omega-3 Fatty Acids as a Treatment Option
- Studies have demonstrated that omega-3 fatty acid supplementation can reduce triglyceride levels and prevent the progression of coronary artery plaque in patients with coronary artery disease on statin treatment 6.
- A plasma omega-3 fatty acid index of ≥4% has been shown to prevent progression of coronary artery plaque in nondiabetic subjects with mean LDL-C <80 mg/dL 6.
- Omega-3 fatty acids may be a useful adjunct to statin therapy in patients with high triglyceride levels and coronary artery disease.
Hypertriglyceridemia as a Risk Factor for Coronary Artery Disease
- Elevated triglyceride levels have been associated with an increased risk of coronary artery disease, particularly in certain subgroups such as women and patients with noninsulin-dependent diabetes 7.
- Hypertriglyceridemia is often a component of atherogenic dyslipidaemia, which includes decreased levels of HDL cholesterol and increased levels of small dense LDL particles 8.
- Therapeutic targeting of hypertriglyceridemia may reduce cardiovascular risk beyond the reduction achieved by LDL-cholesterol lowering 8.