Limits...
Triglyceride-rich lipoproteins and high-density lipoprotein cholesterol in patients at high risk of cardiovascular disease: evidence and guidance for management.

Chapman MJ, Ginsberg HN, Amarenco P, Andreotti F, Borén J, Catapano AL, Descamps OS, Fisher E, Kovanen PT, Kuivenhoven JA, Lesnik P, Masana L, Nordestgaard BG, Ray KK, Reiner Z, Taskinen MR, Tokgözoglu L, Tybjærg-Hansen A, Watts GF, European Atherosclerosis Society Consensus Pan - Eur. Heart J. (2011)

Bottom Line: If inadequately corrected, adding niacin or a fibrate, or intensifying LDL-C lowering therapy may be considered.Treatment decisions regarding statin combination therapy should take into account relevant safety concerns, i.e. the risk of elevation of blood glucose, uric acid or liver enzymes with niacin, and myopathy, increased serum creatinine and cholelithiasis with fibrates.These recommendations will facilitate reduction in the substantial cardiovascular risk that persists in patients with cardiometabolic abnormalities at LDL-C goal.

View Article: PubMed Central - PubMed

Affiliation: European Atherosclerosis Society, INSERM UMR-S939, Pitié-Salpetriere University Hospital, Paris 75651, France. john.chapman@upmc.fr

ABSTRACT
Even at low-density lipoprotein cholesterol (LDL-C) goal, patients with cardiometabolic abnormalities remain at high risk of cardiovascular events. This paper aims (i) to critically appraise evidence for elevated levels of triglyceride-rich lipoproteins (TRLs) and low levels of high-density lipoprotein cholesterol (HDL-C) as cardiovascular risk factors, and (ii) to advise on therapeutic strategies for management. Current evidence supports a causal association between elevated TRL and their remnants, low HDL-C, and cardiovascular risk. This interpretation is based on mechanistic and genetic studies for TRL and remnants, together with the epidemiological data suggestive of the association for circulating triglycerides and cardiovascular disease. For HDL, epidemiological, mechanistic, and clinical intervention data are consistent with the view that low HDL-C contributes to elevated cardiovascular risk; genetic evidence is unclear however, potentially reflecting the complexity of HDL metabolism. The Panel believes that therapeutic targeting of elevated triglycerides (≥ 1.7 mmol/L or 150 mg/dL), a marker of TRL and their remnants, and/or low HDL-C (<1.0 mmol/L or 40 mg/dL) may provide further benefit. The first step should be lifestyle interventions together with consideration of compliance with pharmacotherapy and secondary causes of dyslipidaemia. If inadequately corrected, adding niacin or a fibrate, or intensifying LDL-C lowering therapy may be considered. Treatment decisions regarding statin combination therapy should take into account relevant safety concerns, i.e. the risk of elevation of blood glucose, uric acid or liver enzymes with niacin, and myopathy, increased serum creatinine and cholelithiasis with fibrates. These recommendations will facilitate reduction in the substantial cardiovascular risk that persists in patients with cardiometabolic abnormalities at LDL-C goal.

Show MeSH

Related in: MedlinePlus

Upon entry into the circulation, chylomicrons (containing apo B-48) produced by the small intestine, and VLDL (containing apo B-100) produced by the liver undergo LPL–mediated lipolysis mainly in peripheral tissues, notably adipose tissue and muscle. Intravascular remodelling of TRL equally involves the actions of lipid transfer proteins (CETP, PLTP) and additional lipases (HL and EL) with the formation of remnant particles. TRL remnants are typically enriched in cholesterol and apo E, but depleted in triglyceride; they are principally catabolized in the liver upon uptake through the LRP and LDL receptor pathways. TRL remnants can contribute either directly to plaque formation following penetration of the arterial wall at sites of enhanced endothelial permeability,21 or potentially indirectly following liberation of lipolytic products (such as FFA and lysolecithin) which may activate pro-inflammatory signalling pathways in endothelial cells.20,21 Abbreviations: apo, apolipoprotein; CETP, cholesteryl ester transfer protein; EL, endothelial lipase; FFA, free fatty acids; HL, hepatic lipase; LDL, low-density lipoprotein; LPL, lipoprotein lipase; LRP, lipoprotein receptor-related protein; PLTP, phospholipid transfer protein; TRL, triglyceride-rich lipoprotein; VLDL, very-low density lipoprotein.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC3105250&req=5

EHR112F1: Upon entry into the circulation, chylomicrons (containing apo B-48) produced by the small intestine, and VLDL (containing apo B-100) produced by the liver undergo LPL–mediated lipolysis mainly in peripheral tissues, notably adipose tissue and muscle. Intravascular remodelling of TRL equally involves the actions of lipid transfer proteins (CETP, PLTP) and additional lipases (HL and EL) with the formation of remnant particles. TRL remnants are typically enriched in cholesterol and apo E, but depleted in triglyceride; they are principally catabolized in the liver upon uptake through the LRP and LDL receptor pathways. TRL remnants can contribute either directly to plaque formation following penetration of the arterial wall at sites of enhanced endothelial permeability,21 or potentially indirectly following liberation of lipolytic products (such as FFA and lysolecithin) which may activate pro-inflammatory signalling pathways in endothelial cells.20,21 Abbreviations: apo, apolipoprotein; CETP, cholesteryl ester transfer protein; EL, endothelial lipase; FFA, free fatty acids; HL, hepatic lipase; LDL, low-density lipoprotein; LPL, lipoprotein lipase; LRP, lipoprotein receptor-related protein; PLTP, phospholipid transfer protein; TRL, triglyceride-rich lipoprotein; VLDL, very-low density lipoprotein.

Mentions: The EAS Consensus Panel is well aware of uncertainties and controversies regarding triglycerides and HDL-C levels, both as risk markers or targets of therapy. Triglycerides are predominantly carried in fasting conditions in very low-density lipoproteins (VLDLs) and their remnants, and postprandially in chylomicrons and their remnants. The generic term ‘triglyceride-rich lipoprotein remnants', therefore, relates to chylomicron and VLDL particles which have undergone dynamic remodelling in the plasma after secretion from the intestine (chylomicrons) or liver (VLDL) (Figure 1). This remodelling results in a spectrum of particles which are heterogeneous in size, hydrated density, and lipid and protein composition20 and include intermediate-density lipoprotein (IDL) particles. No single biochemical trait allows the differentiation of remnants from newly secreted chylomicrons, VLDL and IDL.21 Thus, plasma triglyceride levels correspond essentially to the sum of the triglyceride content in nascent VLDL and their remnants in the fasting state, together with that in chylomicrons and their remnants in the postprandial state. Consequently, the Panel has used the generic term ‘triglyceride-rich lipoprotein (TRL) remnants’ as a surrogate for plasma levels of both newly secreted TRLs and their remnants, the latter predominating in the typical person with cardiometabolic risk.21 As discussed below, increasing evidence suggests that remodelled chylomicrons and VLDL are atherogenic, primarily as a result of their progressive enrichment with cholesterol and depletion of triglycerides in the plasma compartment. This process also results in progressive reduction in their size. The term ‘TRL remnants’ has been used to emphasize our focus on atherogenic lipoproteins themselves rather than their major lipids.Figure 1


Triglyceride-rich lipoproteins and high-density lipoprotein cholesterol in patients at high risk of cardiovascular disease: evidence and guidance for management.

Chapman MJ, Ginsberg HN, Amarenco P, Andreotti F, Borén J, Catapano AL, Descamps OS, Fisher E, Kovanen PT, Kuivenhoven JA, Lesnik P, Masana L, Nordestgaard BG, Ray KK, Reiner Z, Taskinen MR, Tokgözoglu L, Tybjærg-Hansen A, Watts GF, European Atherosclerosis Society Consensus Pan - Eur. Heart J. (2011)

Upon entry into the circulation, chylomicrons (containing apo B-48) produced by the small intestine, and VLDL (containing apo B-100) produced by the liver undergo LPL–mediated lipolysis mainly in peripheral tissues, notably adipose tissue and muscle. Intravascular remodelling of TRL equally involves the actions of lipid transfer proteins (CETP, PLTP) and additional lipases (HL and EL) with the formation of remnant particles. TRL remnants are typically enriched in cholesterol and apo E, but depleted in triglyceride; they are principally catabolized in the liver upon uptake through the LRP and LDL receptor pathways. TRL remnants can contribute either directly to plaque formation following penetration of the arterial wall at sites of enhanced endothelial permeability,21 or potentially indirectly following liberation of lipolytic products (such as FFA and lysolecithin) which may activate pro-inflammatory signalling pathways in endothelial cells.20,21 Abbreviations: apo, apolipoprotein; CETP, cholesteryl ester transfer protein; EL, endothelial lipase; FFA, free fatty acids; HL, hepatic lipase; LDL, low-density lipoprotein; LPL, lipoprotein lipase; LRP, lipoprotein receptor-related protein; PLTP, phospholipid transfer protein; TRL, triglyceride-rich lipoprotein; VLDL, very-low density lipoprotein.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3105250&req=5

EHR112F1: Upon entry into the circulation, chylomicrons (containing apo B-48) produced by the small intestine, and VLDL (containing apo B-100) produced by the liver undergo LPL–mediated lipolysis mainly in peripheral tissues, notably adipose tissue and muscle. Intravascular remodelling of TRL equally involves the actions of lipid transfer proteins (CETP, PLTP) and additional lipases (HL and EL) with the formation of remnant particles. TRL remnants are typically enriched in cholesterol and apo E, but depleted in triglyceride; they are principally catabolized in the liver upon uptake through the LRP and LDL receptor pathways. TRL remnants can contribute either directly to plaque formation following penetration of the arterial wall at sites of enhanced endothelial permeability,21 or potentially indirectly following liberation of lipolytic products (such as FFA and lysolecithin) which may activate pro-inflammatory signalling pathways in endothelial cells.20,21 Abbreviations: apo, apolipoprotein; CETP, cholesteryl ester transfer protein; EL, endothelial lipase; FFA, free fatty acids; HL, hepatic lipase; LDL, low-density lipoprotein; LPL, lipoprotein lipase; LRP, lipoprotein receptor-related protein; PLTP, phospholipid transfer protein; TRL, triglyceride-rich lipoprotein; VLDL, very-low density lipoprotein.
Mentions: The EAS Consensus Panel is well aware of uncertainties and controversies regarding triglycerides and HDL-C levels, both as risk markers or targets of therapy. Triglycerides are predominantly carried in fasting conditions in very low-density lipoproteins (VLDLs) and their remnants, and postprandially in chylomicrons and their remnants. The generic term ‘triglyceride-rich lipoprotein remnants', therefore, relates to chylomicron and VLDL particles which have undergone dynamic remodelling in the plasma after secretion from the intestine (chylomicrons) or liver (VLDL) (Figure 1). This remodelling results in a spectrum of particles which are heterogeneous in size, hydrated density, and lipid and protein composition20 and include intermediate-density lipoprotein (IDL) particles. No single biochemical trait allows the differentiation of remnants from newly secreted chylomicrons, VLDL and IDL.21 Thus, plasma triglyceride levels correspond essentially to the sum of the triglyceride content in nascent VLDL and their remnants in the fasting state, together with that in chylomicrons and their remnants in the postprandial state. Consequently, the Panel has used the generic term ‘triglyceride-rich lipoprotein (TRL) remnants’ as a surrogate for plasma levels of both newly secreted TRLs and their remnants, the latter predominating in the typical person with cardiometabolic risk.21 As discussed below, increasing evidence suggests that remodelled chylomicrons and VLDL are atherogenic, primarily as a result of their progressive enrichment with cholesterol and depletion of triglycerides in the plasma compartment. This process also results in progressive reduction in their size. The term ‘TRL remnants’ has been used to emphasize our focus on atherogenic lipoproteins themselves rather than their major lipids.Figure 1

Bottom Line: If inadequately corrected, adding niacin or a fibrate, or intensifying LDL-C lowering therapy may be considered.Treatment decisions regarding statin combination therapy should take into account relevant safety concerns, i.e. the risk of elevation of blood glucose, uric acid or liver enzymes with niacin, and myopathy, increased serum creatinine and cholelithiasis with fibrates.These recommendations will facilitate reduction in the substantial cardiovascular risk that persists in patients with cardiometabolic abnormalities at LDL-C goal.

View Article: PubMed Central - PubMed

Affiliation: European Atherosclerosis Society, INSERM UMR-S939, Pitié-Salpetriere University Hospital, Paris 75651, France. john.chapman@upmc.fr

ABSTRACT
Even at low-density lipoprotein cholesterol (LDL-C) goal, patients with cardiometabolic abnormalities remain at high risk of cardiovascular events. This paper aims (i) to critically appraise evidence for elevated levels of triglyceride-rich lipoproteins (TRLs) and low levels of high-density lipoprotein cholesterol (HDL-C) as cardiovascular risk factors, and (ii) to advise on therapeutic strategies for management. Current evidence supports a causal association between elevated TRL and their remnants, low HDL-C, and cardiovascular risk. This interpretation is based on mechanistic and genetic studies for TRL and remnants, together with the epidemiological data suggestive of the association for circulating triglycerides and cardiovascular disease. For HDL, epidemiological, mechanistic, and clinical intervention data are consistent with the view that low HDL-C contributes to elevated cardiovascular risk; genetic evidence is unclear however, potentially reflecting the complexity of HDL metabolism. The Panel believes that therapeutic targeting of elevated triglycerides (≥ 1.7 mmol/L or 150 mg/dL), a marker of TRL and their remnants, and/or low HDL-C (<1.0 mmol/L or 40 mg/dL) may provide further benefit. The first step should be lifestyle interventions together with consideration of compliance with pharmacotherapy and secondary causes of dyslipidaemia. If inadequately corrected, adding niacin or a fibrate, or intensifying LDL-C lowering therapy may be considered. Treatment decisions regarding statin combination therapy should take into account relevant safety concerns, i.e. the risk of elevation of blood glucose, uric acid or liver enzymes with niacin, and myopathy, increased serum creatinine and cholelithiasis with fibrates. These recommendations will facilitate reduction in the substantial cardiovascular risk that persists in patients with cardiometabolic abnormalities at LDL-C goal.

Show MeSH
Related in: MedlinePlus