Tăng triglyceride máu liệu có còn là yếu tố nguy cơ tim mạch

Are Triglycerides a Cardiovascular Risk Factor? Are Triglycerides a Cardiovascular Risk Factor? Disclosure Information Why this question ? There are a number of different guidelines developed by different international bodies •ACC/AHA ( ? ATP IV ) •ESC/EAS •NLA TG gets little attention in these guidelines ACC/AHA •ACC/AHA guideline is formulated with the evidence derived from the RCT’s or metaanalysis of RCTs •This guideline used the intensity of statin therapy as the goal of treatment •4 groups are identified : reduction in ASCVD events with good margin of safety from moderate- or high intensity statin therapy ACC/AHA Guideline, 2013 •“As of Yet, there are no data to show that adding a non statin drug (s) to high intensity statin therapy will provide incremental ASCVD risk reduction benefit with an acceptable margin of safety” •It asserts that “ future guideline could examine the treatment of hypertriglycerdemia” National Lipid Association guideline 2015 • Primary target is recommended to lower the non-HDL-C, rather than LDL-C • Non-HDL-C = TC- HDL-C • Non-HDL-C include LDL-C and other atherognic cholesterol i.e TG remnants • They have a separate statement emphasising the peculiarity of lipid pattern ( high TG, low HDL-C ) in south asians descent in US ; increased prevalence of metabolic syndrome and possibility of genetic variation in drug metabolism Introduction • For the last decades there is much debate and controversies regarding the causal relationship with high Triglyceride level and cardiovascular diseases • Number of trials and meta analyses showed, the Triglyceride has got the causal relationship with the cardiovascular disease • In most cases, this relationship was found to be attenuated when other co founders were taken into consideration • This statistical dilemma obscures the true status of the triglyceride Introduction • Importance of triglyceride has been reflected in the gradual lowering of the “threshold’’ value over the years TG 1984 NIH Consensus Panel 1993 NCEP guideline 2001 NCEP guideline Desirable 500 mg/dL) denotes a population at substantially greater mortality risk Triglycerides and cardiovascular disease risk • Recent data favour the role of TG-rich lipoproteins as a risk factor for CVD • Large prospective studies have reported that non-fasting TGs predict CAD risk more strongly than fasting TGs Triglycerides and cardiovascular disease risk Recent data from genetic studies utilizing a Mendelian randomization design have consistently linked both non-fasting TG levels as well as remnant cholesterol to increased risk of CVD events and all-cause mortality 2016 ESC/EAS Guidelines for the Management of Dyslipidaemias Strategies to control plasma triglycerides • The first step is to consider possible causes of HTG and to evaluate the total CV risk • The primary goal is to achieve the LDL-C level recommended based on the total CV risk level • However, recent evidence of TGs as a causal risk factor may encourage TG lowering 2016 ESC/EAS Guidelines for the Management of Dyslipidaemias Recommendations for drug treatments of hypertriglyceridaemia Recommendations Class Level Drug treatment should be considered in high-risk patients with TG >2.3 mmol/L (200 mg/dL) IIa B Statin treatment may be considered as the first drug of choice for reducing CVD risk in high-risk individuals with hypertriglyceridaemia IIb B In high-risk patients with TG >2.3 mmol/L (200 mg/dL) despite statin treatment, fenofibrate may be considered in combination with statins IIb C 2016 ESC/EAS Guidelines for the Management of Dyslipidaemias Points to ponder • A number of primary and secondary prevention trials of statins have demonstrated that lowering of LDL-C decreases the incidence of coronary artery disease (CAD) • Still, despite aggressive use of statins, the majority of CAD events are not prevented Points to ponder • Relooking at the residual risk after intensive LDLlowering with statin therapy in diabetic patients with CHD in three important trials (PROVE IT, IDEAL, TNT) to lower LDL-C below 100 mg/dL, we see a significant residual risk remaining after therapy • Although the reduction in the CV risk was statistically significant in these three landmark trials but it was not clinically profound Points to ponder • It was suggested that "this statistically significant but clinically inadequate control of CHD risk is, in part, due to a lipid treatment focus on LDL-C alone with a resultant neglect of other important aspects of lipoprotein metabolism.” • Statin therapy may not eliminate CVD risk associated with low HDL and high TGs Conclusion •Both moderate and severe hypertriglyceridemia are associated with substantially increased total mortality and cardiovascular risk •Role of hypertriglyceridemia in atherogenesis has a multifactorial, biological plausibility as most common forms of TG are associated with metabolic syndrome •Genetic studies strongly support the theory that Hypertriglyceridemia and high concentration of TRL are causal risk factor for cardiovascular diseases and mortality Conclusion •As there is still lacking of robust data from the RCTs , the guidelines are not categorical about the TG as the risk factor to be addressed as LDL-C •With increasing accumulation of evidences the TG as the causal risk factor is on the focus of discussion •Let us have more data to be unequivocal about the role of TG Are Triglycerides a Cardiovascular Risk Factor? Got the answer Yes Thank You… Inviting to Thank You Take home message • Raised serum TG is definitely a risk factor for atherosclerosis • Though the major guidelines did not categorically state the importance of TG as a risk for ASCVD, they considered that this issue should be more studied • For the south-asians, TG stands out an important target for management Take home message • Though statins are the first line of treatment of dyslipidaemis, fibrates, niacins, n-3 fatty acids (fish oils) are the other adjunct drugs • Life style modification remains the initial approach ... Introduction • Triglyceride is one of the major lipoproteins measured in blood- along with LDL and HDL lipoproteins • Triglyceride lipoprotein constitutes of two major components: -Triglyceride. .. concentrated on the role of triglyceride- more scientifically the cholesterol content of triglyceride – remnant cholesterol Three Atherogenic Consequences of Hypertriglyceridemia Possible causes... Residual risk “ is due to cholesterol content of triglyceride • This concept has been reflected by the level set for triglyceride Threshold for Elevated Triglycerides Level •>150 mg/dL (1.7mmol/L)