Tackle the Triglycerides to Reduce ASCVD Risk, ACC Says

Triglyceride-lowering treatments should be considered for reducing atherosclerotic cardiovascular disease (ASCVD) risk among people with persistent hypertriglyceridemia, according to updated guidance.

The 2018 American cholesterol guideline had recommended the use of elevated triglycerides as a risk-enhancing factor in primary ASCVD prevention, with primary lowering of triglycerides as a reasonable strategy in those with triglycerides exceeding 500 mg/dL.

Taking into account newer evidence on non-statin therapies in people with high triglycerides, the American College of Cardiology (ACC) released an Expert Consensus Decision Pathway statement, published in the Journal of the American College of Cardiology.

As in 2018, an ACC writing committee, chaired by Salim Virani, MD, PhD, of Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine in Houston, recommended lifestyle changes as frontline therapy for people with persistent hypertriglyceridemia despite statin therapy:

• Weight loss: an expected 10%-20% reduction in triglycerides in most people (some may see reductions approaching 70%)
• Dietary modifications (e.g., alcohol restriction): over 70% reduction in triglycerides expected
• Physical activity: up to 30% reduction depending on type of activity

Statins are known to provide some reduction in triglycerides in hypertriglyceridemia but are better known for their lowering of LDL cholesterol.

According to Virani’s group, if triglycerides and ASCVD risk remain elevated despite the aforementioned interventions, additional triglyceride risk-based therapies may be considered in some patient groups in an approach based on ASCVD risk, LDL cholesterol, and other factors.

One therapy that may fit the bill is icosapent ethyl (Vascepa).

Published in 2018, the REDUCE-IT trial featured a triglyceride risk-based approach (i.e., including patients with ASCVD or those with diabetes mellitus plus additional ASCVD risk factors and elevated triglycerides) and found the purified omega-3 fatty acid product to have cardiovascular benefits.

That led to icosapent ethyl winning FDA approval for the indication of cardiovascular risk reduction in 2019. The drug had already been approved for triglyceride lowering since 2012.

However, not everything that lowers triglycerides will lower ASCVD risk — for example, other omega-3 fatty acid formulations have failed to reproduce the clinical benefit of icosapent ethyl in REDUCE-IT.

Persistent hypertriglyceridemia is defined by fasting triglycerides exceeding 150 mg/dL following a minimum of 4 to 12 weeks of lifestyle intervention, a stable dose of maximally tolerated statin therapy, as well as evaluation and management of secondary causes of hypertriglyceridemia.

Outcomes trials on more triglyceride risk-based drug candidates are pending and are needed to inform future guidelines, Virani and colleagues said.

The present ACC statement was endorsed by the National Lipid Association.