April 18th, 2011
100 Is the New 150: AHA Lowers Optimal Triglyceride Level
Larry Husten, PHD
In a newly released scientific statement on triglycerides, the AHA recommends that 100 mg/dL replace 150 mg/dL as the upper limit for the “optimal level” for triglycerides. But, the statement acknowledges, the cut point should not be used as a therapeutic target for drug therapy, “because there is insufficient evidence that lowering triglyceride levels” can improve risk. Instead, the statement puts a large emphasis on lifestyle changes, especially with diet and exercise, to cut triglycerides and reduce risk.
The new statement “is not intended to serve as a specific guideline,” according to the AHA, but instead “will be of value” to the Adult Treatment Panel IV (ATP IV) of the National Cholesterol Education Program, which will be available for public review and comment this fall and is expected to be published in the spring of 2012.
“The good news is that high triglycerides can, in large part, be reduced through major lifestyle changes,” said the chair of the committee, Michael Miller, in an AHA press release. “In contrast to cholesterol, where lifestyle measures are important but may not be the solution, high triglycerides are often quite responsive to lifestyle measures that include weight loss if overweight, changes in diet, and regular physical activity.”
The statement includes specific recommendations for reducing added sugar, fructose, saturated fat, trans fat, and alcohol for those with elevated triglycerides. According to the statement, 31% of U.S. adults have triglyceride levels greater than 150 mg/dL.
12 Responses to “100 Is the New 150: AHA Lowers Optimal Triglyceride Level”
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I doubt if there is evidence conclusively in order to associate any increased cardiovascular risk with the level of triglycerides under a value less than 200 mg/dl if there is not another more powerful present
at the same time.
Today I saw in my office a healthy 70 year-old man with no cardiovascular risk factors and a healthy lifestyle. Recently he had lipid testing at a “screening fair,” showing a total cholesterol of 201, HDL of 70, triglycerides of 120, and LDL of 107, similar to past lipid profiles. Pointing to the “H” next to the total cholesterol of 201 on the lab report, he asked, “If this means “high,” don’t I need a cholesterol drug?” If the new AHA Scientific Statement has its way, his triglyceride level would also merit an “H” (high) and I would have even more explaining to do.
To its credit, the new statement does admit that the evidence for TG as an independent predictor of cardiovascular events remains controversial (if one adjusts for other lipid fractions). It also acknowledges the lack of convincing clinical-trial evidence to support the benefits of triglyceride-lowering drug therapies added to conventional statin therapy. Nevertheless, the take-home message of the statement is ambiguous: More patients will be labeled as “diseased” or “abnormal,” and clinicians will perceive that they need to focus more heavily on triglyceride levels. The statement does emphasize lifestyle modification as the major intervention, but do we have any evidence that patients who know their triglyceride levels are more motivated to exercise and lose weight than patients who are similarly counseled, but without a focus on their triglyceride levels? Will clinicians be tempted to add drugs “to get that TG level below 100”? Will patients insist on them? Will drug companies play up the new thresholds?
Just last month, a study published in JAMA (March 23/30 issue) documented that the rate of prescribing fibrates has doubled in the U.S. during the past decade, despite the lack of clinical-trial evidence that justifies this surge in prescribing. Against that background, it is unfortunate that fully 6 of the 12 authors of the new Scientific Statement have financial ties to the maker of Tricor and Trilipix (the disclosures are published near the end of the document). Would it have really been impossible to convene a scientific committee free of those conflicts of interest?
Very controversial update!I don’t understand what purpose will be served if TG level reduced to 100mg/dl. Will it provide any incremental prognostic information about CHD/CVD? Will lowering TG reduce CHD events & mortality?
Are not data of ACCORD & FIELD studies suffice to refute TG-CHD relation?
I afraid like FDA,AHA also become morally corrupt by Big-Pharma!Those who want to boost sell of TG lowering drugs.
I feel very sorry for AHA!!
I see the AHA statement as a complement to recent releases concerning sugar and salt intakes, and as a valuable summary of the current work reflecting the potential significance of hyperTGemia as a risk factor, and role in producing residual risk, particularly in DM and metabolic syndrome. This document is what it says, a scientific statement. For optimal cardiovascular health, TG should be 100 or lower.
The treatment algorithm in Table 5 clearly shows the progression in restriction of added sugars and fructose, total carbohydrate, weight, and rise in dietary EPA/DHA advised as TG levels rise. Pharmacologic therapy is only mentioned for very high TG, at or over 500.
About 5 times as much room is devoted to lifestyle management than pharmacological. Section 17 says “overall, the treatment of elevated TG focuses on intensive TLC…”
While the spin in nonacademic reviews may imply fibrates et al might be used, it is up to the physician to call it like it is–tell patients they need to eat less, clean up their diets, move, and lose weight. Patients will continue to demand any pill that enables them to avoid making fundamental changes–nothing has changed.
Richard Kones
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None.
Do not treat with drugs unless the TG level is >500 mg/dl. When you look closely at the document that is what is says. Seems to me that should have been the headline. The main point of the document seems to be to promote lifestyle changes.
Does anyone know the actual vote (15 to 10, 20 to 5) to lower the accepted TGL level? If it was by a majority of 2, I’m not interested.
Robin… does it matter that much? After the information is available, it is up to the physician to interpret and translate to the patient. From the tone of your question, I think you and most of us agree with Harlan’s paper re fibrate utilization, and will follow Dr Krumholz suggestion above, which in fact was what AHA did say… lifestyle first and foremost, use evidence-based data, and regard the rest as amusement.
Lifestyle transgressions cause 90% of all of the heart disease we see daily. Blending this basic, patient characteristics, and modern drug/surgical therapy in the EBM era is the “new art” of medicine today–alive and well.
Continuing with this theme, today’s TOC from JACC contains a gem discussing this unification in the elderly, really “must” reading at http://content.onlinejacc.org/cgi/content/full/57/18/1801. Truth enough to elicit tears.
Richard Kones
As the triglyceride level goes up, the LDL gets smaller and denser, thus making it more pathogenic. Therefore, we do not need to treat “high” triglycerides over 100 with anything other than diet, exercise and weight loss unless the non HDL cholesterol is above recoommended levels for that patients other risk factors. The AHA recomendation makes sense, it’s just not complete. Someday, we will be checking Apo B levels, making cholesterol, LDL, HDL & triglyceride testing unnecessary. Unfortunately, we haven’t reached that day yet.
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none
Dr. Krumholz must wonder why the headline wasn’t “Do not treat with drugs unless the TG level is >500 mg/dl.” I have become so cynical about the drug company influence that I suspect it even when the setting might just be powerful people not taking into account the effect of their actions. The AHA is still generally accepted as the authority against which the average physician believes he/she will be judged. The average physician may not get beyond the headline so all of the lifestyle recommendations will be overlooked as the physician goes on to see the headlines about back pain and ARB’s and a hundred other topics. Whether this is marketing by the pharmaceutical industry or just carelessness on the part of the AHA, its effects are more likely to be damaging through increased prescription of fibrates than helpful through increased emphasis on lifestyle changes.
Cardio Exchange is an admirable antidote to headline addiction. If only it reached a larger audience.
Competing interests pertaining specifically to this post, comment, or both:
none. Solo private practice outpatient Internal Medicine.
Great comments. I do think the headline should have focused on the new threshold for drug treatment. And will have a contribution about that next week on CardioExchange.
Also, here is my Forbes blog on the increase in sales of fibrates despite recent negative trials. http://blogs.forbes.com/sciencebiz/2011/04/29/why-is-abbotts-trilipix-defying-gravity/
Alan..your healthy guy has a Framingham risk of 10%. Will you consider a CRP and/or CAC score?
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