Understanding hypertriglyceridemia in women: clinical impact and management with prescription omega-3-acid ethyl esters

Figures & data

Figure 1 Influence of aging on TG levels of men and women in three cultures. All TG values between the ethnic groups are significant (P < 0/001) except between Sweden and the US (P = 0.65). In Iranians, the combination of high TG was associated with elevated apo B, suggesting that increased hepatic fatty acid flux may be an important driver of the increased apo B. The increased numbers of TG-rich VLDL result in relative enrichment of LDL and HDL in TG and depletion in cholesterol ester and therefore higher apo B and apo A–I than LDL-C and HDL-C, respectively. Copyright © 2009. Elsevier. Reprinted with permission from Solhpour A, Parkhideh S, Sarrafzadegan N, et al. Levels of lipids and apolipoproteins in three cultures. Atherosclerosis. 2009;207(1):200–207.²⁶

Abbreviations: Apo B, apolipoprotein B; HDL, high-density lipoprotein; HDL-C, high-density lipoprotein cholesterol; LDL, low-density lipoprotein; LDL-C, low-density lipoprotein cholesterol; TG, triglyceride; VLDL, very low-density lipoprotein.

Table 1 NCEP ATP III goals for LDL-C and non-HDL-C in patients with elevated TGs, stratified by CHD risk level^20,41

Risk level	LDL-C	Non-HDL-Ca
CVD plus high-risk factors	<70 mg/dL	<100 mg/dL
CHD or CHD risk equivalent	<100 mg/dL	<130 mg/dL
Multiple (2+) risk factors	<130 mg/dL	<160 mg/dL
0–1 risk factors	<160 mg/dL	<190 mg/dL

Note:

a NCEP ATP III recommends non-HDL-C as a secondary treatment goal in patients with TGs ≥200 mg/dL. Risk factors include age, smoking, hypertension, premature family history of CHD, and low HDL-C.

Abbreviations: CHD, coronary heart disease; CVD, cardiovascular disease; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; NCEP ATP III, National Cholesterol Education Program Adult Treatment Panel III; TGs, triglycerides.

Table 2 Selected statements from American Heart Association guidelines for the prevention of coronary heart disease in women

Lifestyle changes	Statement
Smoking cessation	Do not smoke and avoid environmental tobacco smoke
Physical activity	Minimum of 30 minutes of moderate-intensity physical activity on most, and preferably all, days of the week
Dietary intake	A diet rich in fruits and vegetables; choose whole-grain, high-fiber foods; consume fish, especially oily fish, at least twice a week; limit intake of saturated fat to 10% of energy and, if possible, to 7%, cholesterol to 300 mg/d
Alcohol intake	No more than one drink per day
Weight maintenance/reduction	Women should maintain or lose weight through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to maintain/achieve a BMI between 18.5 and 24.9 kg/m^2 and a waist circumference of 35 inches
Omega-3 fatty acids	As an adjunct to diet, omega-3 fatty acids in capsule form (approximately 850–1000 mg of EPA and DHA) may be considered in women with CHD, and higher doses (2–4 g) may be used for treatment of women with high triglyceride levels
Treatment goals
Major risk factor interventions Lipid and lipoprotein levels: optimal levels and lifestyle	The following levels of lipids and lipoproteins in women should be encouraged through lifestyle approaches: LDL-C < 100 mg/dL HDL-C > 50 mg/dL Triglycerides < 150 mg/dL Non-HDL-C < 1360 mg/dL

Notes: Copyright © 2007. Wolters Kluwer/Lippincott, Williams & Wilkins. Reprinted with permission from Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circulation. 2007;115(11):1481–1501.⁴²

Abbreviations: BMI, body mass index; CHD, coronary heart disease; DHA, docosahexaenoic acid; EPA, eicosapentaenoic acid; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol.

Table 3 Summary of Lipid and Lipoprotein treatment recommendations from ADA/ACCF³⁹ and AACC.⁷²

Treatment goals
Highest-risk level	LDL-C	Non-HDL-C	Apo B	LDL-P
ADA/ACC	<70 mg/dL	<100 mg/dL	<80 mg/dL	-
AACC	< 70 mg/dL	< 80 mg/dL	-	-
High-risk patients
ADA/ACC	< 100 mg/dL	< 130 mg/dL	< 90 mg/dL	-
AACC	< 100 mg/dL	< 120 mg/dL	< 80 mg/dL	1100 nmol/L
Lower-risk patients
AACC	< 130 mg/dL	< 150 mg/dL	100 mg/dL	1400 nmol/L

Abbreviations: LDL-C, low-density lipoprotein cholesterol; non-HDL-C, non-high-density lipoprotein cholesterol; Apo, apolipoprotein; LDL-P, LDL particle count; AACC, American Association of Clinical Chemistry

Figure 2 Effect of P-OM3 vs placebo on lipid parameters in patients with severe hypertriglyceridemia. P values for lipid changes were TGs (P < 0.00001), VLDL-C (P < 0.0001), HDL-C (P = 0.014), and LDL-C (P = 0.0014). Copyright© 2009. GlaxoSmithKline group of companies. Adapted with permission from Copyright© 2009. GlaxoSmithKline group of companies. Adapted with permission from LOVAZA [prescribing information]. Research Triangle Park, NC: GlaxoSmithKline; 2009.⁶⁰

Abbreviations: HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; P-OM3, prescription omega-3-acid ethyl esters; TG, triglyceride; VLDL-C, very low-density lipoprotein cholesterol.

Figure 3 Response to the addition of P-OM3 4 g/d to ongoing simvastatin 40 mg/d therapy in patients with hypertriglyceridemia (TGs ≥ 200 mg/dL and ≤499 mg/dL). Values for differences of non-HDL-C, HDL-C, TGs, and VLDL-C between POM3 and placebo were all significant at P < 0.001 and for apo B P = 0.023. The LDL-C differences were not significant. Copyright © 2007. Elsevier. Adapted with permission from Davidson MH, Stein EA, Bays HE, et al. Efficacy and tolerability of adding prescription omega-3 fatty acids 4 g/d to simvastatin 40 mg/d in hypertriglyceridemic patients: an 8-week, randomized, double-blind, placebo-controlled study. Clin Ther. 2007;29(7):1354–1367.⁵⁹

Abbreviations: Apo B, apolipoprotein B; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; P-OM3, prescription omega-3-acid ethyl esters; TG, triglyceride; VLDL-C, very low-density lipoprotein cholesterol.

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