The Hypertriglyceridemia app assumes that the patient is currently taking or has attempted to take guideline-directed LDL-C–lowering therapies including statin and nonstatin agents
Persistent Hypertriglyceridemia | Fasting triglycerides > 150 mg/dL following a minimum of 4 to 12 weeks of lifestyle intervention, a stable dose of maximally tolerated statin therapy when indicated, as well as evaluation and management of secondary causes of hypertriglyceridemia. Before beginning triglyceride risk-based nonstatin therapies, a fasting lipid panel should be obtained (2 measurements of fasting lipids, preferably at least 2 weeks apart is recommended). |
Fasting vs Nonfasting Lipid Measurement | In most patients, the postprandial rise in triglycerides is small, between 12 and 27 mg/dL. The 2018 AHA/ACC/ multisociety cholesterol guideline recommends that for adults aged > 20 years not taking lipid-lowering drug therapy, either a fasting or nonfasting lipid profile may be used to estimate ASCVD risk and document baseline LDL-C. For those with nonfasting triglycerides > 400 mg/dL, a repeat fasting lipid profile is recommended to assess fasting triglycerides and baseline LDL-C. The Martin-Hopkins method provides accurate assessments of LDL-C in individuals with hypertriglyceridemia. Fasting lipid testing is favored under the following circumstances: a) To establish the diagnosis of the metabolic syndrome, as one of the criteria is fasting triglycerides > 150 mg/dL b) To identify lipid disorders in those without ASCVD, but with a family history of premature ASCVD or genetic lipid disorders c) To assess adherence to lifestyle and medical therapy in those being treated with lipid-lowering medication d) To identify those with triglycerides > 500 mg/dL, who are at risk for hypertriglyceridemia-induced pancreatitis, and monitor their response to therapy. |
Secondary Causes of Hypertriglyceridemia | It is crucial that clinicians investigate and treat secondary causes of hypertriglyceridemia. Diseases, diet/lifestyle, medications, and disorders of metabolism are major causes for elevation of triglycerides that clinicians can use to rule out secondary causes of hypertriglyceridemia. These factors can either cause or contribute to triglyceride elevations in patients. Poor glycemic control may significantly influence plasma lipid levels in patients with diabetes mellitus and significantly exacerbate hypertriglyceridemia. A genetic predisposition to hypertriglyceridemia increases the likelihood and severity of elevated triglycerides in each category. Multifactorial chylomicronemia syndrome is the most common condition that elevates triglyceride levels high enough to cause lipemia retinalis, eruptive xanthomas, abdominal pain, and hyperlipidemic pancreatitis. Clinicians should understand the drugs and conditions which make this disease more likely as pancreatitis associated with hypertriglyceridemia can be fatal. |
Lifestyle Intervention | Lifestyle modification (ie, adherence to a heart-healthy diet, regular physical activity, avoidance of tobacco products, limited alcohol consumption, and maintenance of a healthy weight) remains a critical component of ASCVD risk reduction, both before and in concert with the use of lipid-lowering medications. Referral to a registered dietitian nutritionist is strongly recommended to improve understanding of heart-healthy dietary principles and individualize nutrition recommendations for patients with hypertriglyceridemia. Given that metabolic risk factors such as hypertriglyceridemia cluster with other metabolic risk factors (abdominal obesity, hypertension, hyperglycemia), adherence to a recommended dietary intervention can markedly benefit the entire metabolic risk profile over the life course. Adherence to lifestyle modification should be regularly assessed at the time of initiation or modification of statin therapy and at each patient visit during monitoring of ongoing therapy. |
Role of Statin Therapy in Patients with Hypertriglyceridemia | Although commonly recognized for their impact on LDL-C, statins also provide a 10 to 30% dose-dependent triglyceride reduction in patients with elevated triglyceride levels. Trials have demonstrated those with elevated triglyceride levels are at increased risk of ASCVD events and can achieve ASCVD risk reduction with statin therapy. |
Persistent Hypertriglyceridemia as a Risk-Enhancing Factor in Primary Prevention | Persistently elevated triglycerides (nonfasting triglycerides > 175 mg/dL) are one of the risk-enhancing factors identified by the 2018 AHA/ACC/multisociety cholesterol guideline, according to which the 10-year ASCVD risk derived using the Pooled Cohort Equations (PCE) is a useful tool to predict population risk. However, clinicians should be aware that it has limitations when applied to individuals. The PCE may overestimate risk in individuals from higher socioeconomic status, as well as in those receiving consistent screening and preventive care. One purpose of the discussion is to individualize risk status based on the PCE estimate as well as other factors. These factors may suggest a higher lifetime risk than is denoted by the 10-year risk estimate with the PCE. |
Role of Omega-3 Fatty Acids in Patients with Hypertriglyceridemia |
|
Strategy/Agent | Comments |
---|---|
Referral to lipid specialist |
|
Ezetimibe(36) |
|
PCSK9 inhibitors(37,38) |
|
Bile acid sequestrants(43–46) |
|
Phytosterols |
|
Soluble/viscous fiber |
|
Mipomersen |
|
Lomitapide |
|
LDL Apheresis |
|
ASCVD indicates atherosclerotic cardiovascular disease; BAS, bile acid sequestrant; CHD, coronary heart disease; CV, cardiovascular; GI, gastrointestinal; HDL-C, high-density lipoprotein cholesterol; HeFH, heterozygous familial hypercholesterolemia; HoFH, homozygous familial hypercholesterolemia; INR, international normalized ratio; LDL-C, low-density lipoprotein cholesterol; MI, myocardial infarction; PAD, peripheral arterial disease; PCSK9, proprotein convertase subtilisin/kexin 9; PI, prescribing information; PO, by mouth; REMS, Risk Evaluation and Mitigation Strategy; SQ, subcutaneous; TC, total cholesterol; TG, triglycerides; TSH, thyroid stimulating hormone; UA, unstable angina; and VLDL, very low density lipoprotein.
Strategy/Agent | Comments |
---|---|
1.Potential for additional ASCVD risk reduction from addition of non-statin therapy to evidence-based statin therapy to lower LDL-cholesterol |
|
2. Potential for significant adverse events or drug-drug interactions from addition of non-statin therapy to evidence-based statin therapy for lowering LDL-cholesterol |
|
3. Patient preferences and considerations |
|
*For example, in the Treating to New Targets trial, patients with CHD who received 10 mg of atorvastatin daily had a 5-year event rate of 10.9%, and those who received 80 mg of atorvastatin daily had a 5-year event rate of 8.7%. These numbers (and similar rates from other trials) may inform the number-needed-to-treat. Additional consideration of comorbidities and other poorly controlled or well-controlled risk factors will increase or decrease risk accordingly. Comorbidities are defined as diabetes, recent (<3 months) ASCVD event, ASCVD event while already taking a statin, baseline LDL-C ≥190 mg/dL not due to secondary causes, poorly controlled other major ASCVD risk factors, elevated lipoprotein(a), or chronic kidney disease.
†Use the Pooled Cohort Equations to estimate 10-year ASCVD risk. High-risk markers include 10-year ASCVD risk ≥20%, primary LDL-C ≥160 mg/dL at baseline; poorly controlled other major ASCVD risk factor(s); family history of premature ASCVD with or without elevated Lp(a); evidence of accelerated subclinical atherosclerosis (e.g., coronary artery calcification); elevated hs-CRP; and other risk-modifying conditions, such as CKD, HIV, and chronic inflammatory disorders.
‡Such evidence exists for ezetimibe from the IMPROVE-IT study, with a 6% relative/2% absolute risk reduction in a composite ASCVD endpoint over 7 years when added to a moderate-intensity statin. Short-term data (<18 months) from PCSK9 inhibitors alirocumab and evolocumab suggest more substantial ASCVD risk reduction. Data are lacking for addition of BAS to statins. Niacin preparations have been associated with no benefit and potential for significant harms when added to statin therapy.
§For example, patients on maximally tolerated statin with LDL-C of 130 mg/dL may receive more benefit from addition of a non-statin therapy than those with on-statin LDL-C of 80 mg/dL.
∥For example, when added to statins, ezetimibe may lower LDL-C an additional 20-25% on average; PCSK9 inhibitors may lower LDL-C an additional 60% on average. For each 40 mg/dL reduction in LDL-C using safe and evidence-based therapies, there appears to be an approximate 20% relative risk reduction in ASCVD. This number, combined with the baseline absolute risk, may inform the number-needed-to-treat.
ICD-10 Category | Clinical Criteria | With Generic Testing Performed |
---|---|---|
Heterozygous FH |
|
|
Homozygous FH |
|
|
Family history of FH |
|
|
apoB indicates apolipoprotein B; CAD, coronary artery disease; FH, familial hypercholesterolemia; ICD-10, International Classification of Disease, 10th Revision; LDL, low-density lipoprotein; LDL-C, low-density lipoprotein cholesterol; and PCSK9, proprotein convertase subtilisin/kexin 9. | ||
*Gidding SS, Champagne MA, de Ferranti SD, et al. The agenda for familial hypercholesterolemia: a scientific statement from the American Heart Association. Circulation. 2015;132:2167–92. |
This Terms of Service and License Agreement constitutes a legal agreement (collectively, the "Agreement") between the American College of Cardiology Foundation ("ACCF") and You and your agents ("You") for the use of the Lipid Manager (the "Product"), whether You use the mobile application version of the Product or the web version of the Product. The Product allows You to access certain content included in the Product ("Content") relating to suggested lifestyle interventions or drug therapies to lower triglycerides and/or LDL-C.
By using the Product, You accept and agree to be bound by all of the terms and conditions set forth in this Agreement. If You do not wish to accept the terms and conditions of this Agreement, You may not proceed to use the Product.
ACCF may change the terms of this Agreement from time to time without further notice directly to You. When the terms are changed, ACCF will post a general conspicuous notice. If You do not agree with the revised terms, please discontinue use of the Product immediately. Your continued use of the Product following such notice constitutes your acceptance of and agreement to be bound by any revised terms of the Agreement. This Agreement expressly incorporates by reference and includes rules or disclaimers that may be posted and updated within the Product or communicated to You from time to time.
ACCF may terminate your access and/or the Product at any time. You agree that any termination of your access to the Product shall not result in any liability or other obligation of ACCF to You, or any third party in connection with such termination.
This Product, including the information, text, graphics, images, audio and video files, trademarks and other materials that may be contained therein (collectively "Content"), is owned by ACCF and/or its suppliers and is protected by patents, copyrights, trademarks, and other proprietary rights. Except as specifically provided in this Agreement, your use of the Product shall be governed and constrained by applicable patent, copyright, trademark and other intellectual property laws. ACCF grants You a limited, nonexclusive, nontransferable, revocable license to utilize and access the Product for your noncommercial, personal use according to the terms and conditions in this Agreement. You may not modify, publish, transmit, participate in the transfer or sale of, reproduce, create derivative works from, distribute, perform, display, incorporate into another website, or in any other way exploit the Service and/or any of the Content, in whole or in part. Except as expressly granted by this Agreement, You acquire no right, title or interest in the Product or the Content or other data or materials incorporated in the Product. ACCF, ACC or affiliates or licensors thereof shall retain all right, title and interest in the Product and Content.
TO THE FULLEST EXTENT ALLOWED BY APPLICABLE LAW, ACCF HEREBY DISCLAIMS, AND IN NO EVENT SHALL ACCF OR ANY PARTY INVOLVED IN CREATING OR PRODUCING THE PRODUCT BE LIABLE FOR, ANY DIRECT, INDIRECT, INCIDENTAL, SPECIAL, CONSEQUENTIAL, OR EXEMPLARY DAMAGES, INCLUDING WITHOUT LIMITATION, DAMAGES FOR LOSS OF PROFITS, GOODWILL, USE, DATA LOSS, OR OTHER LOSSES, WHETHER IN AN ACTION OF CONTRACT, NEGLIGENCE OR OTHER TORTIOUS ACTION, EVEN IF ACCF HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES, RESULTING FROM: (i) THE USE OR INABILITY TO USE THE PRODUCT, (ii) THE COST OF ANY SUBSTITUTE PRODUCTS AND/OR SERVICES RESULTING FROM ANY PRODUCTS, DATA, INFORMATION OR SERVICES OBTAINED OR WHICH YOU WERE UNABLE TO OBTAIN OR TRANSACTIONS EFFECTED OR FAILED TO BE EFFECTED, (iii) THE USE OR INABILITY TO USE ANY THIRD PARTY APPLICATIONS CONTAINED WITHIN THE PRODUCT, OR (iv) ANY MATTER OTHERWISE RELATED TO YOUR USE OF THE PRODUCT.
You assume all risks associated with use of the Product including, but not limited to any harm, injury or damages resulting directly or indirectly from the use of the Product, all such risks being known and understood by You. In consideration of your use of the Product, You, for yourself and anyone entitled to act on your behalf, waive and forever release ACCF, its officers, trustees, employees, representatives and successors from all claims and liabilities of any kind arising out of your use or misuse of the Product.
You hereby agree to indemnify, save and hold ACCF, its directors, officers, shareholders, parents, subsidiaries, affiliates, agents and licensors harmless from and against any and all claims, liability, losses, damages and costs, including, without limitation, reasonable attorneys' fees and costs, arising out of your use or misuse of the Product or Content, or any violation of this Agreement. ACCF assumes the right, at your expense, to assume the exclusive defense and control of any matter for which you are required to indemnify ACCF, and you agree to cooperate with ACCF’s defense of these claims. ACCF will use reasonable efforts to notify you of any such claim, action, or proceeding upon becoming aware of it.
THE PRODUCT AND CONTENT ARE PROVIDED ON AN "AS IS" AND "AS AVAILABLE" BASIS. ACCF AND ITS SUPPLIERS EXPRESSLY DISCLAIM ALL WARRANTIES OF ANY KIND WITH RESPECT TO THE PRODUCT OR CONTENT, WHETHER EXPRESS OR IMPLIED, INCLUDING IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, TITLE AND NON-INFRINGEMENT. ACCF MAKES NO WARRANTY THAT THE PRODUCT AND/OR ANY CONTENT THEREIN WILL MEET YOUR REQUIREMENTS, OR WILL BE UNINTERRUPTED, TIMELY, SECURE, CURRENT, ACCURATE, COMPLETE OR ERROR-FREE OR THE RESULTS THAT MAY BE OBTAINED BY USE OF THE PRODUCT OR ANY CONTENT THEREIN WILL BE ACCURATE OR RELIABLE. YOU UNDERSTAND AND ACKNOWLEDGE THAT YOUR SOLE AND EXCLUSIVE REMEDY WITH RESPECT TO ANY DEFECT IN OR DISSATISFACTION WITH THE PRODUCT IS TO CEASE ITS USE.
The Content on the Product is presented as an educational service intended for licensed healthcare professionals. While the Content in the Product is about specific medical and healthcare issues, the Content is not a substitute for or replacement of personalized medical advice and is not intended to be used as the sole basis for making individualized medical or health-related decisions.
The views and opinions expressed are those of the contributing authors and editors and do not necessarily represent the views of the ACCF. The material is not intended to present the only, or necessarily best, methods or procedures for the medical situations addressed, but rather is intended to represent an approach, view, statement or opinion.
Any reference to a specific therapy or commercial product in this Product does not constitute a guarantee or endorsement by ACCF of the quality or value of such therapy or product or any claims made by the manufacturer of such therapy or commercial product.
In addition, any statements about such therapy or commercial products are solely based on published clinical prediction rules and estimates of drug treatment effects from published clinical studies and do not represent an ACCF endorsement or evaluation of these products.
ACCF will be excused from performance under this Agreement and will not be liable or considered in default under this Agreement in the event that the Product is unavailable for any period of time, or if ACCF is otherwise unable to perform its obligations hereunder, in whole or in part, as a result of a Force Majeure Event. For purposes of this Section, "Force Majeure Event" means an event or series of events caused by or resulting from any of the following: (1) weather conditions or other elements of nature or acts of God; (2) government regulation; (3) quarantines or embargoes; (4) telecommunications, network, computer, server or Internet downtime; (5) unauthorized access to ACCF's information technology systems by third parties; or (6) any other causes beyond the reasonable control of ACCF.
This Agreement is personal to You, and You may not assign your rights or obligations to anyone.
Neither failure nor delay on the part of any party to exercise any right, remedy, power or privilege hereunder nor course of dealing between the parties shall operate as a waiver thereof, or of the exercise of any other right, remedy, power or privilege. No term of this Agreement shall be deemed waived, and no breach consented to, unless such waiver or consent shall be in writing and signed by the party claimed to have waived or consented. No waiver of any rights or consent to any breaches shall constitute a waiver of any other rights or consent to any other breach.
If any provision in this Agreement is held invalid or unenforceable under applicable law, the remaining provisions shall continue in full force and effect.
This Agreement will be governed by and construed exclusively in accordance with the laws of the District of Columbia, USA, without regard to its conflicts of law principles and, to the extent applicable, the federal laws of the United States. If a dispute arises between ACCF and You, You hereby agree to submit such dispute to non-binding mediation, followed by binding arbitration, if necessary. Both the mediation and arbitration will be conducted by JAMS applying the laws of the District of Columbia without regard to its conflicts of laws principles and in the District of Columbia as venue.
I hereby certify that I understand and agree to the terms stated in this Agreement and that this Agreement applies to my initial use of the Product and all other subsequent uses of the Product. BY USING THIS PRODUCT, I HEREBY AFFIRM THAT I HAVE READ, FULLY UNDERSTAND, AND AGREE TO THE ABOVE STATEMENTS.
March 2022
The ACC Lipid Manager app is meant to be used in relation to patients who may need lifestyle intervention or drug therapy to lower their triglycerides and/or LDL-C, particularly with the goal to lower their risk for heart disease and stroke.
The ACC Lipid Manager app contains four tools to help clinicians manage a patient’s CV risk from therapy initiation through treatment calibration with a goal of lowering ASCVD risk:
Each tool within the app is designed to be used on its own or in combination to manage a patient’s therapy throughout their continuum of care. The Lipid Manager App aims to streamline use at point of care by offering access to all of ACC’s Lipid management tools from one place.
Advice from the LDL-C Lowering Therapy tool is derived from the 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk, meant to address current gaps in care for LDL-C lowering by providing firmer and more specific guidance on the adequacy of statin therapy and whether or when to use non-statin therapies if response to statins is deemed inadequate. The app is intended for use with patients who are currently taking or who have attempted to take a statin.
The ACC Statin Intolerance App guides clinicians through the process of managing and treating patients who report muscle symptoms while on statin therapy. The information and recommendations in this app are derived from the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, and the prescribing information for each statin.
Hypertriglyceridemia is a tool based on the 2021 ACC Expert Consensus Decision Pathway on the Management of ASCVD Risk Reduction in Patients With Persistent Hypertriglyceridemia. Consensus recommendations are provided for clinicians and patients regarding unique aspects of lifestyle interventions for management of hypertriglyceridemia and the use of statins and triglyceride risk-based nonstatin therapies for ASCVD risk reduction in the following patient groups with persistent hypertriglyceridemia:
The ASCVD Risk Estimator within this app offers the same functionality as ACC’s pre-existing app of the same name. It is intended as a companion tool to the 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk and the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. This Risk Estimator enables health care providers and patients to estimate 10-year and lifetime risks for atherosclerotic cardiovascular disease (ASCVD), defined as coronary death or nonfatal myocardial infarction, or fatal or nonfatal stroke, based on the Pooled Cohort Equations and lifetime risk prediction tools. The Risk Estimator is intended for use with patients without ASCVD with a LDL-cholesterol <190 mg/dL.
The information and recommendations in this App and all its component tools are meant to support clinical decision making. They are not meant to represent the only or best course of care, or replace clinical judgment. Therapeutic options should be determined after discussion between the patient and their care provider.
Tools within the app were designed and vetted through collaboration with writing committee members from each of the ACC clinical policy source documents, members of the LDL Think Tank Work Group, and the ACC Best Practices and Quality Improvement Subcommittee. It was further refined via user testing with physicians, nurse practitioners, pharmacists, and other specialties.
This was developed as part of the ACC's Lipid Management Solutions Initiative. Financial support for the Initiative was provided by Amgen Inc. All of the content was independently developed with no sponsor involvement.
Please see the Resources section of this App for links to additional references.
For Support
Call: (202) 375-6000, ext. 5603 or (800) 253-4636
Email: membercare@acc.org
This
version of the application has been
locked because of need to
ugrade the science.
Please go to the store upgrade this
application.