Remnants of Residual Risk: Triglycerides Predict Recurrent Events
JACC in a Flash | Among patients with acute coronary syndrome (ACS) treated effectively with statins, fasting triglycerides may predict long-term and short-term cardiovascular risk, according to a study published May 27 in JACC.
The study, based on analysis of patients in both the dal-OUTCOMES trial and the atorvastatin arm of the MIRACL (Myocardial Ischemia Reduction with Acute Cholesterol Lowering) trial, examined long-term and short-term relationships of triglycerides to risk after ACS. Analysis of dal-OUTCOMES included 15,817 patients (97% statin-treated) randomly assigned four to 12 weeks after ACS to either dalcetrapib or placebo and followed for a median 31 months. Analysis of MIRACL included 1,501 patients treated with atorvastatin 80 mg daily beginning 1 to 4 days after ACS and followed for 16 weeks.
Overall results found fasting triglyceride levels were associated with both long-term and short-term risk after ACS. In the dal-OUTCOMES Trial, long-term risk increased across quintiles of baseline triglycerides and researchers noted no interaction of triglycerides and treatment assignment on the primary outcome. In the atorvastatin group of MIRACL, short-term risk increased across tertiles of baseline triglycerides, with a hazard ratio of 1.51 (95% confidence interval: 1.05 to 2.15) in highest/lowest tertiles (>195/≤135 mg/dl). According to the study authors, the relationship of triglycerides to risk was independent of low-density lipoprotein cholesterol in both studies.
“Despite a background of effective statin treatment, we found a strong, unfavorable relationship of fasting triglyceride levels to long-term and short-term prognosis after ACS,” study authors said. “The hazard associated with increasing triglycerides was nearly identical in univariate analysis and after adjustment for risk factors usually associated with triglyceride levels, including age, sex, hypertension, smoking, diabetes, HDL-C, and body mass index, as well as LDL-C. This observation suggests that triglyceride-rich lipoproteins may have a causal relationship to risk after ACS.”
Moving forward, the authors note it remains uncertain whether triglyceride-rich lipoproteins should be a target of therapy after ACS “above and beyond” statin treatment. Future studies will need to specifically examine the efficacy of triglyceride-lowering interventions after ACS.
“The questions of whether residual risk for recurrent atherosclerotic cardiovascular disease can be attributed to remnant lipoproteins, and to what degree, carry significant potential therapeutic implications, said Parag H. Joshi, MD, MHS, and colleagues in an accompanying editorial comment. “With the rise in metabolic syndrome and resultant increases in remnants, lifestyle modifications take on even greater importance as part of a structured preventative program.”
- Schwartz GG, Abt M, Bao W, et al. J Am Coll Cardiol. 2015;65(21):2267-2275.
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