Peter Toth: Triglycerides as a Predictor of CV Risk

At the American Diabetes Association's 78th Annual Scientific Sessions, Peter Toth, MD, the director of preventive cardiology at the CGH Medical Center in Sterling, Illinois, sat with MD Mag to discuss recent study results he presented at the meeting.

The study, conducted in 11,000 patients with either diabetes, atherosclerotic cardiovascular disease (ASCVD), or both, revealed for the first time that triglycerides can be utilized as an independent predictor of cardiovascular risk—a landmark moment.

Additionally, in a cost-analysis, the findings showed that having hypertriglyceridemia can increase monthly health care costs by 14%, and increased hospitalization length by 17%. Meanwhile, having diabetes showed a monthly health care cost increase of 43%, and a hospitalization cost increase of 45%.

Peter Toth, MD:

We're presenting data here based on an OPTUM database, in a retrospective analysis of high-risk patients. We took about 11,000 patients who either have diabetes or ASCVD, or both, and we asked a very simple question: If a patient has triglycerides of 200 mg/dL to 499 mg/dL and you compare them to patients whose triglycerides are less than 150 mg/dL with an high-density lipoprotein (HDL) above 40 mg/dL—so they don't meet criteria for metabolic syndrome, by way of example—is there a difference in cardiovascular outcomes over about a 4 year follow-up period?

Everyone in the study was on a statin—and I'm happy to say that half of all the patients were women and half were men, so both sexes are well represented—and over the course of the follow-up period, we found that, for the patients who had the hypertriglyceridemia, the risk of sustaining an acute cardiovascular event, so all MACE, was increased by about 35%. The risk of sustaining a non-fatal myocardial infarction (MI) increased 34%. The risk of a non-fatal stroke increased 27%.

The risk of requiring revascularisation via percutaneous transhepatic cholangiography (PTC) or coronary artery bypass graft (CABG) was 51% higher in the patients whose triglycerides were just over 200.

The other important thing was that, if you had hypertriglyceridemia, your average monthly health-related costs increased 14% and if you were hospitalized, you were hospitalized 17% longer. Now, in a related way, just having diabetes increased your monthly health-related cost by about 43% and increased any hospitalization cost by 45%.

What I'm very happy to report here is that the relationship between the elevation in triglyceride and augmented risk for cardiovascular events actually held even after adjusting for low-density lipoprotein (LDL) cholesterol, non-HDL cholesterol, and HDL cholesterol, and this is one of the very first studies to demonstrate that. So, truly, triglycerides did emerge as an independent predictor of future cardiovascular events.

We pose the argument that this explains, to some degree, why there continues to be residual risk as you observed in studies like PROVE-IT, where having a triglyceride level above 150 mg/dL was actually associated with a 27% higher residual risk for sustaining an acute cardiovascular event. Basically, we've got LDL licked because we can just about take it to ridiculously low levels—less than 25 mg/dL, and in some patients, even less than 10 mg/dL.

But there's still a signal for risk in trials like FOURIER and ODYSSEY OUTCOMES, so where else is risk coming from? Well, obviously, if you're diabetic. There's risk coming from diabetes, there's risk coming from poorly controlled hypertension, if you're still a smoker, etc. But we do believe that the triglycerides are significantly contributing to what we call residual risk.

Transcript edited for clarity.

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