Triglycerides, atherosclerosis, and cardiovascular outcome studies: Focus on omega-3 fatty acids

Yehuda Handelsman, Michael Shapiro

    Research output: Contribution to journalReview article

    19 Citations (Scopus)

    Abstract

    Objective: To provide an overview of the roles of triglycerides and triglyceride-lowering agents in atherosclerosis in the context of cardiovascular outcomes studies. Methods: We reviewed the published literature as well as ClinicalTrials.gov entries for ongoing studies. Results: Despite improved atherosclerotic cardiovascular disease (ASCVD) outcomes with statin therapy, residual risk remains. Epidemiologic data and recent genetic insights provide compelling evidence that triglycerides are in the causal pathway for the development of atherosclerosis, thereby renewing interest in targeting triglycerides to improve ASCVD outcomes. Fibrates, niacin, and omega-3 fatty acids (OM3FAs) are three classes of triglyceride-lowering drugs. Outcome studies with triglyceride-lowering agents have been inconsistent. With regard to OM3FAs, the JELIS study showed that eicosapentaenoic acid (EPA) significantly reduced major coronary events in statin-treated hypercholesterolemic patients. Regarding other agents, extended-release niacin and fenofibrate are no longer recommended as statin add-on therapy (by some guidelines, though not all) because of the lack of convincing evidence from outcome studies. Notably, subgroup analyses from the outcome studies have generated the hypothesis that triglyceride lowering may provide benefit in statin-treated patients with persistent hypertriglyceridemia. Two ongoing OM3FA outcome studies (REDUCE-IT and STRENGTH) are testing this hypothesis in high-risk, statin-treated patients with triglyceride levels of 200 to 500 mg/dL. Conclusion: There is consistent evidence that triglycerides are in the causal pathway of atherosclerosis but inconsistent evidence from cardiovascular outcomes studies as to whether triglyceride-lowering agents reduce cardiovascular risk. Ongoing outcomes studies will determine the role of triglyceride lowering in statin-treated patients with high-dose prescription OM3FAs in terms of improved ASCVD outcomes.

    Original languageEnglish (US)
    Pages (from-to)100-112
    Number of pages13
    JournalEndocrine Practice
    Volume23
    Issue number1
    DOIs
    StatePublished - Jan 1 2017

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    Omega-3 Fatty Acids
    Atherosclerosis
    Triglycerides
    Outcome Assessment (Health Care)
    Hydroxymethylglutaryl-CoA Reductase Inhibitors
    Cardiovascular Diseases
    Niacin
    Fenofibrate
    Fibric Acids
    Cardiovascular Agents
    Eicosapentaenoic Acid
    Hypertriglyceridemia
    Prescriptions
    Guidelines

    ASJC Scopus subject areas

    • Endocrinology, Diabetes and Metabolism
    • Endocrinology

    Cite this

    Triglycerides, atherosclerosis, and cardiovascular outcome studies : Focus on omega-3 fatty acids. / Handelsman, Yehuda; Shapiro, Michael.

    In: Endocrine Practice, Vol. 23, No. 1, 01.01.2017, p. 100-112.

    Research output: Contribution to journalReview article

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    abstract = "Objective: To provide an overview of the roles of triglycerides and triglyceride-lowering agents in atherosclerosis in the context of cardiovascular outcomes studies. Methods: We reviewed the published literature as well as ClinicalTrials.gov entries for ongoing studies. Results: Despite improved atherosclerotic cardiovascular disease (ASCVD) outcomes with statin therapy, residual risk remains. Epidemiologic data and recent genetic insights provide compelling evidence that triglycerides are in the causal pathway for the development of atherosclerosis, thereby renewing interest in targeting triglycerides to improve ASCVD outcomes. Fibrates, niacin, and omega-3 fatty acids (OM3FAs) are three classes of triglyceride-lowering drugs. Outcome studies with triglyceride-lowering agents have been inconsistent. With regard to OM3FAs, the JELIS study showed that eicosapentaenoic acid (EPA) significantly reduced major coronary events in statin-treated hypercholesterolemic patients. Regarding other agents, extended-release niacin and fenofibrate are no longer recommended as statin add-on therapy (by some guidelines, though not all) because of the lack of convincing evidence from outcome studies. Notably, subgroup analyses from the outcome studies have generated the hypothesis that triglyceride lowering may provide benefit in statin-treated patients with persistent hypertriglyceridemia. Two ongoing OM3FA outcome studies (REDUCE-IT and STRENGTH) are testing this hypothesis in high-risk, statin-treated patients with triglyceride levels of 200 to 500 mg/dL. Conclusion: There is consistent evidence that triglycerides are in the causal pathway of atherosclerosis but inconsistent evidence from cardiovascular outcomes studies as to whether triglyceride-lowering agents reduce cardiovascular risk. Ongoing outcomes studies will determine the role of triglyceride lowering in statin-treated patients with high-dose prescription OM3FAs in terms of improved ASCVD outcomes.",
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