Triglycerides Linked to Risk for Heart Disease

High levels of triglycerides are strong predictors of cardiac trouble and this strengthens the case for including measurement of the blood fats in prevention programs, says a study in the Journal of the American College of Cardiology.

“Triglycerides traditionally have been viewed as second-class citizens,” says lead author Dr. Michael Miller, at the University of Maryland Medical Center.

“LDL cholesterol has always taken center stage,” says Dr. Miller. “We know that LDL is intimately involved in bringing cholesterol to scavenger cells, which deposit them to form plaques in the arteries.

“This study shows that triglycerides in and of themselves are also lipids to blame,” notes Dr. Miller.

Under 150 on Triglycerides is Best

The original study was designed to test the effectiveness of two LDL-lowering statins called Pravachol® and Lipitor® in reducing recurring coronary disease after a heart attack.

The new study went over the data on the 4,162 participants in the trial, looking at the association between triglyceride levels and the incidence of heart problems and death.

“The patients who had heart attacks came back after 30 days,” says Dr. Miller. “We measured LDL levels and triglyceride levels and followed them over the next two years, evaluating for the occurrence of new events and death. If a patient had triglyceride levels below 150 [milligrams per deciliter], there was a 27 percent lower risk of having a new event over time,” he says.

“After multiple adjustments for such things as age, diabetes, high blood pressure, and obesity, the risk reduction was 20 percent,” Dr. Miller explains.

Unlike LDL cholesterol, for which there is a recommended blood level of 70 or below, there is no recommended blood triglyceride level but 150 milligrams per deciliter or below is “considered as desirable,” says Dr. Miller.

When the participants were divided into four groups on the basis of both LDL and triglyceride levels, those in the group with under 150 for triglycerides and under 70 for LDL did the best.

They had a 28 percent lower risk than those in the group with the highest readings for both LDL and triglycerides, he says.

“At the present time, we don’t have a recommendation for triglyceride lowering, so the next logical step is a study to determine whether lowering triglycerides and LDL reduces risk more than lowering LDL alone,” he says. Two such studies are in progress, he notes.

Mediterranean Diet a Good Approach

Previous research has already pointed toward such a connection: A study that appeared in the medical journal Neurology last December found a link between triglycerides and stroke risk.

And research published in the Journal of the American Medical Association (JAMA) last July showed that when high triglyceride levels showed up in nonfasting cholesterol tests, there was an increased risk for a future heart attack.

Dr. Leslie Cho of the Women’s Cardiovascular Center at the Cleveland Clinic, notes that the new report “is not a huge surprise.”

She says, “The unique thing about this study is that even if you control bad LDL cholesterol to less than 70, you still need to look at triglycerides.”

The problem with triglycerides is that “they are the most unstable fats in the body,” so that at least two readings are needed to get an accurate measure of blood levels, she explains.

Dr. Miller says, “I am proactive about both LDL cholesterol and triglycerides.”

Several measures can be taken to lower triglyceride levels – many of them are already recommended on general principles for reduction of coronary risk.

One is to eat a Mediterranean diet, rich in fish. Omega-3 fatty acids can lower triglyceride levels, as can niacin, and exercise has a beneficial effect, says Dr. Miller. Statins also have some triglyceride-lowering effect, he notes.

“If you can effectively get both LDL cholesterol and triglycerides down, you are going to do better,” says Dr. Miller.

Always consult your physician for more information.

Surgery Tops Stents for Multiple Heart Blockages

Bypass surgery provides a lower risk of death and heart attacks than do stents for people with blockages of at least two heart arteries, says a report in the New England Journal of Medicine (NEJM).

The finding is far from the last word on the stent-versus-surgery debate in such cases, says study author Dr. Edward L. Hannan, at the State University of New York at Albany.

“But there isn’t any other study right now that is better than this,” he says. “Physicians need to inform patients about these results and need to engage in a dialogue that includes these findings to determine what is the proper treatment for multi-vessel disease.”

Further Studies Will Define State-of-the-Art

Dr. Hannan studied the outcomes of more than 17,400 procedures for people with multiple blocked coronary arteries.

The outcomes were consistently better in an 18-month follow-up for bypass surgery than for the artery-opening procedure called angioplasty followed by insertion of a drug-coated tube known as a stent.

For example, 92.1 percent of those who had surgery for three blocked arteries had no heart attacks and were alive, compared to 89.7 percent of those who got stents.

For those with two blocked arteries, the comparable numbers were 94.5 percent for surgery and 92.5 for stent implants.

The study was not a randomized, controlled trial, which is regarded as the gold standard for medical research.

It was observational, meaning that the researchers simply recorded what happened in medical practice rather than trying to control all the factors involved in choosing a treatment.

“But the randomized trials done in the past have not necessarily been better,” explains Dr. Hannan. “They were restricted to patients who were not very sick, and they also did not recognize that when you compare two treatments, some patients might not prefer the one that is more invasive.”

Surgery is more invasive than angioplasty, since it requires the chest to be cut open. Angioplasty is done by threading a flexible tube called a catheter through a blood vessel into the heart.

One shortcoming of the study is the relatively short follow-up period of 18 months, says Dr. Joseph P. Carrozza, at Harvard Medical School, who wrote an accompanying editorial.

“One would like to see patients followed for up to five years,” says Dr. Carrozza.

“There is nothing in this study that makes us feel surgery is the treatment of choice for patients with multi-vessel disease,” he adds.

Such a verdict will have to wait on the results of several randomized trials now underway, says Dr. Carrozza.

“This is just one piece of evidence we have right now before we get the final word, he explains.

And yet, Dr. Carrozza says, “This is the first really large study to look at this issue now” and thus should be considered by physicians and heart patients requiring treatment for blocked coronary arteries.

Types of Stents Compared in Second Study

Another report in the same issue of the journal compared the safety of bare-metal to drug-coated stents for so-called “off-label” uses – implants for conditions where there is no formal government approval.

About half of all stent implants are for such conditions.

Questions have been raised about the safety of drug-coated stents in off-label conditions, said a report by a group led by Dr. Oscar C. Marroquin, at the University of Pittsburgh.

But the study of 6,551 cases found a lower rate of complications and no increased risk of death or heart attack for drug-coated stents as compared to the bare-metal kind.

“These findings support the use of drug-eluting stents for off-label indications,” the researchers write.

That report comes on the heels of a study of off-label use of a different kind of stent, developed for use against bile duct obstructions in cancer patients.

More than 1 million patients got stents for off-label conditions between 2003 and 2006, according to a report by Dr. William Maisel, director of the Medical Safety Device Institute at Beth Israel Deaconess Medical Center in Boston.

Some 1,000 malfunctions of the devices were reported, with 81 percent of them in off-label uses.

Always consult your physician for more information.