*For medical professionals only
“img class=”content ” sizes=”(min-width: 320px) 320px, 100vw” src=”https://mmbiz.qpic.cn/mmbiz_png/x5F5KAyDKw19I4VvcibrfNia7lD1fial5KribXqZxjxMxtoc3ichKKz6ib3w5kJias8QNRBYGn80MM0AxEgOvRLib>p>width=”6400″ >Recently, Circulation magazine published an opinion article evaluating the significance of high circulating triglycerides and giving practical clinical advice, let’s take a look!
Although the management of low-density lipoprotein cholesterol (LDL-C) to reduce the risk of atherosclerotic cardiovascular disease (ASCVD) is important Sexuality has been demonstrated, butthe optimal treatment regimen for mildly or markedly elevated circulating triglycerides remains uncertain.
LDL-C and triglyceride concentrations are largely independently regulated: triglycerides can be increases in the case of , and vice versa. There is growing evidence from genetic analyses and Mendelian randomization studies that elevated triglyceride concentrations are causally associated with ASCVD risk, independent of LDL cholesterol.
This supports the hypothesis that larger triglyceride-rich VLDL particles also carry apoB (lipoprotein B ), increased ASCVD risk. However, triglyceride-lowering pharmacological interventions generally failed to affect ASCVD outcomes, most notably fibric acid, niacin, and fish oil preparations, except for individual eicosapentaenoic acid preparations.
Except for uncommon hereditary dyslipidemia (including monogenic and polygenic), if the patient is referred to the cardiometabolic/cardiovascular prevention clinic When the underlying cause is not treated, and only the treatment of elevated triglyceride levels is concerned, the opportunity for intervention will be missed.
There are several secondary causes of elevated triglycerides, such as nephrotic syndrome, liver disease, alcoholism, high carbohydrate/high calorie diet , obesity, and hypothyroidism. In addition, in people with diabetes, especially those with severe insulin resistance, poor glycemic control leads to elevated triglyceride levels that improve with improved glycemic control.
Most importantly, mildly or severely elevated blood triglycerides often Representing the circulating manifestation of ectopic fat in the context of obesity, the liver produces more VLDL particles when visceral and hepatic fat are elevated. This results in excess energy being converted to fat in visceral and ectopic tissues, such as skeletal muscle, liver, pancreas, and heart; but often also in the form of circulating triglycerides.
Blood chemistry, patient history, and some clues from physical examination may help determine When high circulating triglyceride levels may represent excess ectopic fat:
In overweight/obesity, elevated circulating triglycerides are often associated with liver Coexisting steatosis, liver fat can be inferred by direct (ultrasound or magnetic resonance imaging) measurements or by indirect intermediate measurements (ie, alanine aminotransferase [ALT] or gamma-glutamyl transpeptidase [GGT] levels).
These factors related to liver fat and high triglycerides were particularly strongly associated with the risk of developing diabetes, more strongly than the risk of developing ASCVD. This fat-related high triglyceride often coincides with a mild or significant increase in blood sugar. Associated elevations in ALT levels tend not to exceed the traditional upper limit of normal because even circulating levels of 30 to 35 U/L are independently associated with higher diabetes risk (compared to levels <20 U/L), and many People with normal ALT levels may have excess liver fat.
When checked together, selected blood tests: triglycerides, ALT, GGT and glycated hemoglobin (HbA1c) and/or fasting Blood sugar, which can indicate the presence of ectopic fat in the liver and other sites. Because type 2 diabetes is a disease of excess ectopic fat in most people, knowledge of the patient’s weight and their family history of diabetes can also help to better understand the biochemical outcomes.
Figure 1 Whether the height is consistent with the pattern of ectopic fat,
Note that not every patient with ectopic fat will have all the characteristics.
It is not uncommon for patients with ectopic fat to have mildly elevated ALT (usually at the high end of the normal range ± glutamine elevation). In some cases, ALT levels can be higher than the upper limit of normal, which supports nonalcoholic fatty liver disease, especially when alcohol intake is low. GGT levels can also be mildly elevated in many people with ectopic fat. Evidence of abnormal glucose metabolism is also common in patients with ectopic fat (eg, elevated HbA1c in the prediabetic range or more) or with a family history of type 2 diabetes and excess body weight. Being aware of this common type helps doctors explain to patients the cause of elevated triglyceride levels (that is, poor storage of fat due to excess weight), which may help motivate patients to make lifestyle changes and lose weight. If the patient loses weight, the associated blood parameters tend to improve simultaneously, providing positive feedback of health benefits. This is important because deliberate weight loss can reduce the risk of diabetes and cardiovascular disease, and can help patients avoid more medication. Identifying this pattern is increasingly important as obesity andThe number of associated metabolic disorders is increasing, and it is worth noting that secondary causes of elevated triglycerides should be excluded first.
Typical Cases
45< span>year-old male patient, noASCVDhistory, taking statins,LDL-Creachedtarget,
seeing doctor for elevated triglycerides :
Triglycerides: 490 mg/dL;
LDL-C: 74 mg/dL;
HDL-C: 35 mg/dL.
Has a family history of type 2 diabetes and consumes very little alcohol.
Body mass index (BMI) of 29, waist circumference of 38 inches, and about 20 kg heavier than 3 years ago.
Other blood test results are as follows:
ALT, 45 u/L;
Aspartate aminotransferase [AST], 32 U/L;
GGT, 32 U/L;
HbA1c, 46 mmol/mol (6.4%).
Three years ago, triglycerides were 196 mg/dL and ALT was 22 U/L.
These results strongly suggest that the patient’s current high triglyceride levels are a manifestation of ectopic fat, with excess fat, and diabetes. Prior evidence (based on family history), and based on high-normal ALT levels, liver fat levels are likely elevated.
In the context of susceptibility to type 2 diabetes, weight gain will contribute to ectopic fat gain.
It is important to note that there are no clear signals associated with alcohol abuse, (as HDL cholesterol and aspartate aminotransferase levels were not elevated, while GGT levels were only mildly elevated, which is not uncommon in fatty liver disease).
While some may argue that other examinations are needed to better understand the root cause, in this case there is good evidence showed that lifestyle changes that prioritize diet-induced weight loss and increased physical activity can reduce ectopic fat, which can lead to parallel improvements in triglyceride, ALT (and/or GGT), and HbA1c levels.
In fact, the observation of this relative improvement provides indirect biological support for the lifestyle-mediated efficacy of ectopic fat reduction. Additionally, providing feedback on these biochemical changes can help motivate patients to maintain their weight loss and lifestyle changes.
It is worth noting that intentional weight loss itself and lowering associated triglyceride levels also reduce ASCVD risk and, unlike many medications, life Changes in approach also improve quality of life.
In addition, a series of blood tests may help reveal patterns of ectopic fat loss and gain in many patients.
Therefore, it is often possible to predict whether a patient will gain or lose weight with blood results in hand, even before a virtual or in-person visit to actually reach weight.
Summary
Although there are ASCVDExcellent tool for risk factors, and new tools may emerge, but discussing ectopic fat in cardiology isnecessarybecauseOverweightand associated ectopic fat (fatty liver, high blood glyceride levels) and 2diabetes are increasingly common.
Therefore, when faced with a patient with elevated triglycerides, it is generally recommended that clinicians first examine whether this abnormality represents ectopic fat, before and after weight changes , testing for common hepatic adipose intermediates (ALT±GGT), dysglycemia (HbA1c), and liver ultrasound or magnetic resonance imaging in some centers.
In this way, lifestyle changes are motivated and prioritized, resulting in multiple “upstream” health benefits in addition to “downstream” cardiovascular risk reduction benefit.
Source:
High Circulating Triglycerides Are Most Commonly a Marker of Ectopic Fat Accumulation: Connecting the Clues to Advance Lifestyle Interventions. Circulation. 2022;146:77–79. DOI: 10.1161/CIRCULATIONAHA.122.060411
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