Steven Nissen: Why Triglyceride Levels Matter

Do triglyceride levels in the blood matter to the heart?

Steven E. Nissen: Almost everyone knows his or her cholesterol level and understands the importance of this laboratory test as a predictor of the risk of heart disease. However, when physicians measure cholesterol, they almost always also measure a fatty substance known as triglycerides, the same kind of fat that's in foods and gets stored on our bodies. When high levels of triglycerides circulate in the blood they become a health and heart risk.

Normal levels of triglycerides are less than 150 mg/dL. Levels greater than 500mg/dL are particularly concerning because they are associated with development of pancreatitis, a serious and painful inflammation of the gland that gives us digestive enzymes and insulin.

Although triglyceride levels are considered less reliable as a predictor of heart disease than, say, the bad LDL cholesterol, triglycerides are important, in large part because of the company they keep: They often signal a disease state known as metabolic syndrome. Individuals with metabolic syndrome, in addition to high triglyceride levels, generally have high blood pressure, borderline diabetes, abdominal obesity—the proverbial apple shape—and low levels of the good cholesterol (HDL). And this constellation is a heart attack and stroke waiting to happen.

Abdominal obesity itself is a cause of high triglycerides, but so are other factors such as imbibing too much alcohol or regularly feasting on a carbohydrate-rich diet. Cutting down on either of these dietary factors lowers triglycerides. So do other lifestyle measures like regular exercise and weight loss, which can reduce triglyceride levels by as much as 50 percent. Therefore, such lifestyle measures are first steps for any patient in order to bring down their triglycerides.

However, if levels are dangerously high (more than 500 mg/dL), most physicians will move quickly to drug therapy. Statins like Zocor, Lipitor, or Crestor, well known for their cholesterol-lowering ability, also reduce triglycerides by up to 25 percent. More effective is another class of drugs, the fibrates (example: fenofibrate or Tricor), which can lower triglycerides by 30 percent or more. The B-vitamin niacin, given in very high dosages under a physician's guidance (1,000 mg or more) is useful in some patients.

Surprisingly, one of the most effective treatments is fish oil, but you must take a lot of this supplement, generally 4-10 capsules daily. Fish oil is so effective that a prescription brand was approved a few years ago (Lovaza), which is highly concentrated so that fewer capsules are required.

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