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Triglycerides as a Risk Factor for Cardiovascular Disease. Bart Staels. INSERM UR545; Institut Pasteur de Lille; Université Lille Nord de France Lille, France. Triglycerides and CVD. • Epidemiological studies. • Intervention studies. • Niacin. • Fibrates. - PowerPoint PPT Presentation
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Bart Staels
INSERM UR545; Institut Pasteur de Lille; Université Lille Nord de France
Lille, France
Triglycerides as a Risk Factor for Cardiovascular Disease
Triglycerides and CVD
• Epidemiological studies
• Intervention studies
• Pathophysiology of atherogenic dyslipidemia
• Niacin• Fibrates
• Genes and genome-wide association studies
PROCAM Study
Are triglycerides an independent risk factor?
Mls
/ 1
00
0/
10
ye
ars
TriglyceridesTertiles(mg/dL)
LDL-Cholesterol tertiles(mg/dL)
0
50
100
150
200
<132 132-162 >162
< 104
< 104-165
>165
Triglyceride Level Is An Independent CVD Risk Factor
Recent Meta-analysis of 29 Studies
Sarwar N, et al. Circulation. 2007;115:450–458*Individuals in top versus bottom third of usual log-triglyceride values, adjusted for at least age, sex, smoking status, lipid concentrations, and blood pressure (most)
CHD Risk Ratio* (95% CI)
1.72 (1.56-1.90)
21
Duration of follow-up≥10 years 5902
<10 years 4256
SexMale 7728
Female 1994
Fasting statusFasting 7484Nonfasting 2674
Adjusted for HDL-CYes 4469No 5689
N=262 525
Groups CHD Cases
Overall CHD Risk Ratio*Decreased
RiskIncreased
Risk
(440 mg/dL)
(<90)
Age (yr)0 50 60 70 80 90 100
Cu
mu
lativ
e in
cid
enc
e (
%)
0
20
40
60
80
100
5
12 - 3
Triglycerides(mmol/L)
Myocardial infarction in CCHSWomen
N=7600Follow-up: 28 years
Nordestgaard et al. JAMA 2007
PROVE IT-TIMI-22 post-hoc analysis: on-treatment elevatedtriglycerides (>200 mg/dL) significantly increased the risk of death, MI or ACSin patients who achieved LDL cholesterol levels <70 mg/dl on statin therapy Miller M et al J Am Coll Cardiol 2008;51:724
0
5
10
15
20
25
30-d
ay r
isk
of d
eath
, MI
Or
recu
rren
t AC
S (
%)
>200(n=603)
<200(n=2,796)
on-treatment TG (mg/dL)
20.3
13.5RR0.64 (0.53-0.78)P=0.001
High triglycerides contribute to the residual risk after statin treatment
Triglycerides and CVD
• Epidemiological studies
• Intervention studies
• Pathophysiology of atherogenic dyslipidemia
• Niacin• Fibrates
• Genes and genome-wide association studies
Reduction in plasma triglycerides (start >1.5 mmol/L)R
edu
ctio
n i
n i
sch
emic
hea
rt d
isea
se 0%
-10%
-30%
-20%
-40%
0% -10%
-20%
-30% -40% -50%
Helsinki IV
VA-HIT
Helsinki IIBBIP
Post hoc subanalysis of double-blind trials
Carlson & Rosenhamer
Randomized trial unblinded
FIELD
Nordestgaard 2010
Triglycerides and CVD
• Epidemiological studies
• Intervention studies
• Pathophysiology of atherogenic dyslipidemia
• Niacin• Fibrates
• Genes and genome-wide association studies
Statin+niacin vs statin+ezetimibe on lipids – ARBITER 6
Statin+niacin vs statin+ezetimibe on lipids – ARBITER 6
Taylor et al, NEJM, 361:2113-2122, 2009
Statin + niacin is more effective at reducing CIMT than statin plus ezetimibe - ARBITER 6
Statin + niacin is more effective at reducing CIMT than statin plus ezetimibe - ARBITER 6
Major CVD events were lower in the niacin than in the ezetimibe groupMajor CVD events were lower in the niacin than in the ezetimibe group (1% vs. 5%, P=0.04)(1% vs. 5%, P=0.04)
Taylor et al, NEJM, 361:2113-2122, 2009
Triglycerides and CVD
• Epidemiological studies
• Intervention studies
• Pathophysiology of atherogenic dyslipidemia
• Niacin• Fibrates
• Genes and genome-wide association studies
mitochondrial FA-oxidation
TG secretion
Fibrates
PPAR
Fibrates control triglyceride andremnant-lipoprotein metabolism
Liver
Plasma TG
apo A-Vproduction
apo C-IIIproduction
TG clearance
sdLDL
PControl
<.024.1% 34%2.7%4081 HHS Primary Prevention
Rel.RRDrugNTrial
Major CVD Event Rate
.2615.0% 9.4%13.6%3090 BIPSecondary Prevention
.00621.7% 22%17.3%2531 VA-HIT
Diabetic dyslipidemia or Metabolic Syndrome subgroupsvs overall population
FIELD .1611.7% 11%10.4%9795
Mixed (Primary+Secondary)
Fibrates decrease CV risk in patients with metabolic syndrome and diabetic dyslipidemia
0.00717.8% 26%13.5%2014MS Dyslipidemia
.03 18.4% 25%14.1%1470MS
<.00513.0% 71%3.9%292MS dyslipidemia
.00436.5% 32%24.5% 769Diabetics
Scott R et al Diabetes Care 2009; 32:493-498
*HDL-c: <40 mg/dL(men) and <50 mg/dL (women)
Allpatients
5-ye
ar to
tal C
VD
eve
nt r
ate
(%)
0
5
10
15
20
13.912.5
Hazard ratio:(95%) Cl:P-value:
0.89(0.80-0.99)
P=0.035
Low HDL-C
15.1
13.0
0.85(0.74-0.97)
P=0.02
TG>150mg/dL
15.4
13.6
0.88(0.75-1.01)
P=0.07
Low HDL-C +TG>200 mg/dL
17.8
13.5
0.74(0.59-0.92)
P=0.01
Highest therapeutical benefit of fenofibrate in patients with elevated TG and low HDL cholesterol
(FIELD study)
Triglycerides and CVD
• Epidemiological studies
• Intervention studies
• Pathophysiology of atherogenic dyslipidemia
• Niacin• Fibrates
• Genes and genome-wide association studies
Nature Genetics 2008;40,161
GWAS Identify Genes Involved in Triglyceride MetabolismAssociated with CAD Risk
Genes in plasma triglyceride metabolism:LPL, ApoCIII, ApoAI-CIII-AIV, Apo AV, ANGPTL3
Genes in hepatic triglyceride synthesis:GCKR, MLXIPL
Other:TRIB1
ApoCIII Underlies the Abnormal Metabolism of VLDL and LDL in HyperTG and with a High-Carbohydrate Diet
VLDL CIII+Large TG-rich nascent particle
LDL CIII+TG-rich remnant
Dense LDL CIII-Dense LDL CIII-Major LDL TypeMajor LDL Type
TG
TG
Zheng C, Sacks F. JLR 2007;48:1190
++
++
Slow clearance
-
-
++
-CIII
Zheng C. Am J Clin Nutr 2008;88:272
Caron S & Staels B, Circ Res 2008
ApoCIII : a link between hypertriglyceridemiaand vascular dysfunction?
Triglyceride-richLipoproteins (Lp)
TG-richLipo-
proteins
apoCIII
TriglycerideMetabolism
VLDL production
TG metabolism
TG-rich Lp/VLDLclearance
TG-rich Lp/VLDLuptake
Blood
Adhesion moleculeexpression (VCAM-1,ICAM-1)
Endothelial cells
NO production
vasoconstriction
Endothelial dysfunction –Inflammation
1-integrin expression
Monocytes
Monocyte adhesion
on ECs
TLR2 activation
Micro- & Macrovascular diseases (CVD)
CARE
Triglycerides and Apo CIII in VLDL and LDL to Predict CHD
Univariate
RR
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
Q1 Q2 Q3 Q4 Q5
Triglycerides
p=0.03
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
Q1 Q2 Q3 Q4 Q5
Apo CIII in VLDL+ LDL
Triglycerides (NS)
p=0.04
Multivariate
RR
Sacks, Alaupovic, et al. Circulation 2000;102:1886
ApoCIII Genetic Variant Correlates with Triglyceridesand Coronary Artery Calcification
Pollin T. et al. Science 2008;322,1702
0
1000
2000
3000
4000
5000
6000
7000
8000
29 39 49 59 69 79 89 99
Age (years)
Co
ron
ary
Art
ery
Ca
lcif
ica
tio
n
RR
RX
Triglycerides and CVD
• Epidemiological studies
• Intervention studies
• Pathophysiology of atherogenic dyslipidemia
• Niacin• Fibrates
• Genes and genome-wide association studies
The Metabolic Syndrome:a Major Health Problem
Control of plasma triglyceridemetabolism
Plasma TG
apo A-V/apo CIIIproduction
LPLproduction
Lipolytic activity/TG clearance
sdLDL
hepaticlipogenesis
mitochondrial FA-oxidation
TG secretion
Insulin Resistance and Dyslipidemia
TGTG Apo BApo B
VLDLVLDL (large)(large)
IA Fat CellsIA Fat Cells
InsulinInsulin
IRIR XX
LiverLiver
FFAFFACytokineCytokine
ss
LDLLDL
(CETP)(CETP) TGTGCECE
(( HL) HL) Small DenseSmall Dense
LDLLDLLDL
CECE
TGTG
(CETP)(CETP) HDLHDL22
(( HL) HL)
KidneyKidney
Apo A-1Apo A-1
HDL3
FFA: Free fatty acidsCETP: Cholesteryl ester transfer proteinHL: Hepatic lipase
Liver
Adipocytes
NEFA
TG
HSL
Lipolysis
HYPERGLYCEMIAHYPERINSULINEMIA FA TG
TG
TGLipogenesis EsterificationTG
TG
TG
CM
Gut
-oxidation
VLDL
Hepatic lipid accumulation is related to insulin resistanceand associated with increased VLDL1 production
Triglycerides and CVD
• Epidemiological studies
• Intervention studies
• Pathophysiology of atherogenic dyslipidemia
• Niacin• Fibrates
• Genes and genome-wide association studies
• Conclusions
Elevated TG is marker for atherogenic remnant lipoproteins
Although unclear whether TG is a direct cause of CAD, it is a marker for:
• Increased small-dense LDL particles
• Decreased HDL2 cholesterol
• Increased remnant lipoproteins
Causal factor with variation
Glucose
Longterm monitoring
HbA1c
TG Remnants HDL
Nordestgaard et al. Current Drug Targets, 2009, 10, 328-335