In the lipid arena, lowering LDL-C continues to be a major focus for reducing the risk of cardiovascular events. Cardiovascular outcomes trials have shown benefit with ever-lower LDL-C levels and even a growing armamentarium of drugs. Yet there's residual risk that continues to contribute to a risk of cardiovascular events that is too high, including in patients whose triglyceride levels remain elevated despite optimized statin therapy.

What is needed to bring triglycerides down to the levels required to reduce this residual risk? According to a recent ACC survey of cardiologists and cardiovascular team (CV Team) members who treat patients with dyslipidemia or hypertriglyceridemia, education and evidence from cardiovascular outcomes trials of effective agents that reduce events are among the top needs and challenges.

Conducted online from October to December 2017, the survey was sent to 3,648 cardiovascular specialists and had an 8 percent response rate. Results showed that 82 percent of the 156 responding cardiologists and 88 percent of the 149 responding CV Team members want more education to expand their knowledge about hypertriglyceridemia. Of the cardiologists, 54 percent cited the lack of evidence from outcomes trials as the primary current challenge, compared with 28 percent of the CV Team. Patient adherence to treatment is the top challenge cited by CV Team members at 54 percent, compared with 37 percent of cardiologists.

Of the respondents, the cardiologists see a mean of 40 patients with dyslipidemia a week and the CV Team members see a mean of 34 patients. In cardiology practices, a mean 22 percent of patients have a triglyceride level ≥200 mg/dL, compared with 31 percent of patients seen by CV Team members.

Related to the need for education, a lack of education and understanding was reported by 18 percent and 34 percent of the cardiologists and CV Team members; lack of familiarity with guidelines by 14 percent and 18 percent; and lack of understanding of guideline-supporting evidence by 29 percent and 31 percent, respectively.

Cardiologists are more familiar with most of the lipid clinical trials than CV Team members, with about half of cardiologists and about a quarter of the CV Team extremely or very familiar with the PROVE-IT and AIM-HIGH trials. However, less than about 10 percent of both groups are familiar with the STRENGTH and PROMINENT studies. Notably, cardiologists were significantly less familiar with the lipid trials than with non-lipid trials listed in the survey, such as SPRINT.

Among other current challenges for treating hypertriglyceridemia are therapeutic benchmarks that are inconsistent say 31 percent and 28 percent of cardiologists and CV Team members; lack of treatment options say 29 percent and 24 percent; polypharmacy say 43 percent and 46 percent; and side effects say 28 and 34 percent. Medication cost is a challenge according to 28 percent and 44 percent, and prior authorization and insurance denials according to 19 percent and 34 percent of cardiologists and CV Team members.

Cardiologists and CV Team members share a similar perception of the patients who are at the greatest cardiovascular risk. Patients with an acute coronary syndrome (ACS) plus high triglycerides have the highest risk, say 61 percent and 58 percent of the cardiologist and CV Team respondents respectively. Twenty-two percent of each group say high LDL-C presents the highest risk. In patients with hypertriglyceridemia and controlled LDL-C, comorbidities (diabetes, kidney disease and obesity) are thought to pose the highest risk for events by 9 percent of cardiologists and 17 percent of CV Team members. Nearly half (46 percent) of CV Team members but 22 percent of cardiologists think a low HDL-C places a patient at the lowest risk.

When assessing risk factors for diagnosing hypertriglyceridemia, medical history is most relied upon (by 96 percent of cardiologists and 90 percent of CV Team members) followed by diet and alcohol consumption (90 percent of each group); family history (78 percent and 80 percent); physical signs (67 percent and 68 percent); and LDL-C and HDL-C levels (62 percent and 73 percent).

Of note, less than half of cardiologists (49 percent) and CV Team members (36 percent) state they are extremely or very confident about diagnosing and treating hypertriglyceridemia. Cardiologists are less confident regarding hypertriglyceridemia than atrial fibrillation and familial hypercholesterolemia, while CV Team members are more confident in their knowledge of hypertriglyceridemia than familial hypercholesterolemia.

Another common perception among cardiologists and CV Team respondents is that the most important step to reducing risk is to optimize LDL-C levels independent of triglyceride levels (71 percent and 54 percent, respectively). More investigation is needed to determine the magnitude of the risk of triglycerides, according to 70 percent of both groups. Fifty-four percent of cardiologists and 47 percent of CV Team members say that reaching target triglyceride levels can reduce risk, and 27 percent and 35 percent say that triglycerides are a major risk factor for CV events. Just 13 percent of cardiologists and 8 percent of CV Team members think lowering LDL-C alone is sufficient to address risk.

When do they start treatment of hypertriglyceridemia? Among cardiologists, 45 percent start when fasting triglycerides are >200 mg/dL and 42 percent start when the levels are >500 mg/dL. For CV Team members, 20 percent start treatment when fasting triglycerides exceed 150 mg/dL, 46 percent when they are >200 mg/dL, and 29 percent start when the levels are >500 mg/dL. The threshold for treatment is lower for both cardiologists and CV Team members when a patient has one or more risk factors or comorbidities, with 70 percent and 52 percent respectively starting treatment when triglycerides exceed 200 mg/dL.

Interestingly, when it comes to treating patients with controlled LDL-C but elevated triglycerides, cardiologists and CV Team members alike first reach for fibrates (46 and 48 percent respectively) and then prescription Omega-3 (31 percent and 28 percent). Only about 17 percent of both ranked fish oil dietary supplement as their first choice and it was niacin for only 7 percent of both groups.

Regarding familiarity with available medical therapies, more cardiologists are extremely or very familiar with fibrates and niacin (79 percent and 74 percent), compared with fish oil dietary supplements and prescription Omega-3 (68 percent and 65 percent). About 60 percent of CV Team members were extremely or very familiar with each category.

Importantly, there's low satisfaction with current medication options to treat hypertriglyceridemia. Only 27 percent of cardiologists and 23 percent of CV Team respondents are satisfied – and 32 percent and 31 percent are very dissatisfied.

Look for more insights from this survey and perspectives in the full article in the April issue of Cardiology magazine.

This research was sponsored by Amarin.

Keywords: Fibric Acids, Niacin, Risk Factors, Triglycerides, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Fasting, Hyperlipoproteinemia Type II, Atrial Fibrillation, Personal Satisfaction, Acute Coronary Syndrome, Benchmarking, Specialization, Cardiovascular Diseases, Hypertriglyceridemia, Diet, Obesity, Fatty Acids, Omega-3, Dietary Supplements, Patient Compliance, Polypharmacy, Comorbidity, Alcohol Drinking, Kidney Diseases, Diabetes Mellitus

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