ASCVD risk with persistent hypertriglyceridaemia: What is the latest guidance from ACC?

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Recent guidance on the management of persistent hypertriglyceridaemia from the American College of Cardiology (ACC) reflects evolving understanding of residual cardiovascular risk in patients whose triglyceride (TG) levels are raised despite the use of statins.¹

Dr Michael Miller, Professor of Cardiovascular Medicine at the University of Maryland, Baltimore, USA, and co-author of the publication explains that the ACC’s expert consensus decision pathway stratifies patients with atherosclerotic cardiovascular disease (ASCVD) and persistent hypertriglyceridaemia according to their residual LDL-cholesterol (LDL-C) level. 

In all adults with ASCVD and fasting TG ≥150 mg/dL (≥1.7 mmol/L) or non-fasting TG ≥175 mg/dL (2.0 mmol/L) and TG < 500 mg/dL (<5.6 mmol/L), secondary causes of hypertriglyceridaemia should be excluded, and lifestyle, diet, glycaemic control and statin therapy optimised. Following these interventions, those with persistent fasting hypertriglyceridaemia should be stratified to an LDL-C risk-based approach, a combined TG/LDL-C risk-based approach or a TG risk-based approach.

For patients with LDL-C > 100 mg/dL (2.6 mmol/L), an LDL-C risk-based approach is recommended, with further optimisation of statin therapy and adherence, and LDL-C-guided non-statin therapy to be considered in line with the 2018 American Heart Association/ACC cholesterol management guidelines.

For patients with LDL-C of 70-99 mg/dL (1.8-2.6 mmol/L), a combined TG/LDL-C risk-based approach is recommended, based on patient preference. Options are for an LDL-C risk-based approach as above or a TG risk-based approach including consideration of medication known to reduce CV risk in patients with elevated TG, eg. icosapent ethyl.

For patients with LDL-C < 70 mg/dL (1.8 mmol/L), a TG risk-based approach is recommended with consideration given to treatment with icosapent ethyl.

An extended version of this article is available here » Read article

Reference

1. Virani SS, Morris PB, Agarwala A et al. 2021 ACC Expert consensus decision pathway on the management of ASCVD risk reduction in patients with persistent hypertriglyceridemia. J am Coll Cardiol 2021; Aug, 78 (9) 960–993