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Q&A: Targeting hypertriglyceridemia reduces CV events
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A new approach to reducing the risk for major CV events has been to lower triglyceride levels. Seth J. Baum, MD, FASPC, chief medical officer of Excel Medical Clinical Trials, clinical affiliate professor of biomedical science at Florida Atlantic University in Boca Raton and president of the American Society for Preventive Cardiology, spoke with Cardiology Today about treatment options and further research that must be done to learn more about this fairly new development.
Question: What are the challenges of hypertriglyceridemia?
Answer: The interesting thing about triglycerides is just a few years back, we thought that HDL was causally related to heart disease and triglycerides were a bystander. But we’ve learned that it’s the opposite. We’ve learned through genetics and Mendelian randomization studies that triglyceride elevations will lead to an increased risk for MI, stroke and death. We do have to manage high triglycerides differently. This is an area of great research. We are learning a lot about this.
Q: Is hypertriglyceridemia a CV risk factor?
A: I think at this point, it is safe to say that, yes.
Q: How can hypertriglyceridemia be treated?
A: There are many different medications that can lower triglycerides. Even statins have a very powerful effect on triglycerides. Omega-3 fatty acids in fish and fish oils can lower triglycerides. There are some novel medications that are currently in clinical trials, especially for some of the severe states of hypertriglyceridemia, but probably the most effective treatment at this point is through diet and exercise: avoiding simple carbohydrates, avoiding saturated fat depending on what the mutation might be, maintaining an optimal weight and exercising on a regular basis.
Q: What may be available in the future for treatment of hypertriglyceridemia?
A: An antisense oligonucleotide, volanesorsen (Ionis/Akcea), did very well in a clinical trial. There are other drugs also being studied for this. There are two very large trials, STRENGTH and REDUCE-IT, looking at omega-3 fatty acids. They are outcomes trials looking at whether specific forms of omega-3 fatty acids will decrease CV events. There’s a lot of work to be done in this area, and there are other novel drugs as well that are in the pipeline.
Q: What are some key points that clinicians can learn about hypertriglyceridemia?
A: We have to look at triglycerides differently now and take them more seriously. They are a CV risk factor and there are a variety of different causes of hypertriglyceridemia. These range from the nongenetic causes to genetic causes that are more minor, from single nucleotide polymorphisms to familial chylomicronemia syndrome, a rare disorder caused by large effect mutations that can be devastating, causing life-threatening pancreatitis and potentially leading to CVD down the road. We have to learn about genetics of the different forms of hypertriglyceridemia and we also have to broaden our management for hypertriglyceridemia. We need to always emphasize therapies like therapeutic lifestyle changes. Therapeutic lifestyle changes, diet, exercise and the maintenance of optimal weight is important in every aspect of cardiology, and frankly, such lifestyle changes spill over into every other disease state. Therapeutic lifestyle changes reduce not only heart disease, but also cancer, dementia and arthritis.
Q: What does this mean for clinical practice?
A: When you see someone with high triglycerides now, you have to act on it. You have to have the same talk that you would have had regarding the importance of LDL on CVD. That talk must occur for high triglycerides, and then therapeutics have to be applied.
Q: What other research would you like to see done in this area?
A: It’s more of the same. More genetic studies, more studies looking at different therapeutic agents, and ultimately more outcomes trials with these agents. I’d also like to see a better delineation or definition of familial chylomicronemia syndrome because familial chylomicronemia syndrome was defined many years ago and needs a new look. – by Darlene Dobkowski
Disclosure: Baum reports he has given a talk and has been on the scientific advisory board for Akcea and is a principal investigator for the STRENGTH trial sponsored by AstraZeneca.