Letters to the Editor

Original Article: Management of Hypertriglyceridemia

Issue: May 1, 2007

Available at: http://www.aafp.org/afp/20070501/1365.html

Postprandial Triglyceride Levels and Cardiovascular Risk

TO THE EDITOR: The article on hypertriglyceridemia by Drs. Oh and Lanier nicely summarizes our current understanding of hypertriglyceridemia and its management. However, there is no mention of the impact of postprandial hypertriglyceridemia on cardiovascular risk, especially in patients with type 2 diabetes. Although fasting triglyceride levels are routinely measured in clinical practice, studies indicate that postprandial hypertriglyceridemia may be more closely related to atherosclerosis.1-3 Results from the Physicians' Health study suggest that nonfasting or postprandial triglyceride levels strongly predict risk of myocardial infarctions.2 Postprandial levels of chylomicron remnants have been shown to strongly correlate with the rate of progression of coronary lesions.4 Postprandial hypertriglyceridemia also results in endothelial dysfunction through oxidative stress, and this effect is abrogated by antioxidants.5 Negative effects on coagulation activation and inflammation have also been demonstrated.6 Therefore, it is important not to lose sight of this postprandial phenomenon, because most of the day is spent in the postprandial state and studies now implicate it as a strong predictor of cardiovascular events.

John R. Kapoor, MD, PhD

Stanford, CA 94305
E-mail: jkapoor@stanford.edu

Author disclosure: Nothing to disclose.

REFERENCES

1. Groot PH, van Stiphout WA, Krauss XH, et al. Postprandial lipoprotein metabolism in normolipidemic men with and without coronary artery disease. Arterioscler Thromb. 1991;11(3):653-662.

2. Stampfer MJ, Krauss RM, Ma J, et al. A prospective study of triglyceride level, low-density lipoprotein particle diameter, and risk of myocardial infarction. JAMA. 1996;276(11):882-888.

3. Teno S, Uto Y, Nagashima H, et al. Association of postprandial hypertriglyceridemia and carotid intima-media thickness in patients with type 2 diabetes. Diabetes Care. 2000;23(9):1401-1406.

4. Karpe F, Steiner G, Uffelman K, Olivecrona T, Hamsten A. Postprandial lipoproteins and progression of coronary atherosclerosis. Atherosclerosis. 1994;106(1):83-97.

5. Anderson RA, Evans ML, Ellis GR, et al. The relationships between post-prandial lipaemia, endothelial function and oxidative stress in healthy individuals and patients with type 2 diabetes. Atherosclerosis. 2001;154(2):475-483.

6. Silveira A, Karpe F, Johnsson H, Bauer KA, Hamsten A. In vivo demonstration in humans that large postprandial triglyceride-rich lipoproteins activate coagulation factor VII through the intrinsic coagulation pathway. Arterioscler Thromb Vasc Biol. 1996;16(11):1333-1339.

in reply: I appreciate the letter from Dr. Kapoor and agree that the body of literature is growing showing an increased cardiac risk for hypertriglyceridemia in any form-fasting or postprandial. Nonfasting triglyceride elevations have been associated with increased risk of coronary events in a recent cohort study.1 Despite the association, we need large scale, randomized trials to determine if reducing elevated triglyceride levels decreases overall mortality and cardiovascular events. Folic acid and hormone therapy for the prevention of cardiovascular disease are just two examples of overgeneralizing from positive cohort studies before negative randomized controlled studies were performed. Until then, we recommend that clinicians continue to follow the National Cholesterol Education Program guidelines-first work on low-density lipoprotein cholesterol goal, then work on non-high-density lipoprotein cholesterol as a secondary goal in overall lipid management.2

Robert C. Oh, MD, MPH

Honolulu, HI 96859
E-mail: roboh98@gmail.com

Author disclosure: Dr. Oh purchased stocks with Pfizer Pharmaceuticals, Inc., the manufacturer of Lipitor; Merck and Co., the manufacturer of Zocor; and Teva Neuroscience, Inc., after submitting his article "Management of Hypertriglyceridemia" to AFP, but prior to the publication of this letter.

REFERENCES

1. Nordestgaard BG, Benn M, Schnohr P, Tybjaerg-Hansen A. Nonfasting triglycerides and risk of myocardial infarction, ischemic heart disease, and death in men and women. JAMA. 2007;298(3):299-308.

2. Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III): final report. NIH publication no.: 02-5215. Bethesda, Md.: National Heart, Lung, and Blood Institute, 2002.

Corrections

The article "Differential Diagnosis of the Swollen Red Eyelid" (December 15, 2007, page 1815) contained an error regarding internal hordeolum. On page 1822, the third paragraph of the left column, should read: "An internal hordeolum is a staphylococcal infection of a meibomian gland. It is unilateral and presents with pain, eyelid edema, and erythema more diffuse than that of an external hordeolum." The online version of this article has been corrected.

The Tips from Other Journals article "New Guideline for Travel Medicine," (September 15, 2007, page 878) contained an error in Table 2 on page 883. The dosage for atovaquone/proguanil (Malarone) was incorrectly listed as "250/100 mg every day, beginning one to two days pretravel and continuing until 28 days posttravel." The correct dosage is "250/100 mg every day, beginning one to two days pretravel and continuing until seven days posttravel." The online version of this article has been corrected, and the corrected table is reprinted below.

Table 2. Antimalarial Medication Recommendations by Destination
Destination	Medication
Argentina and Paraguay, Central America, Haiti and Dominican Republic, Middle East	Chloroquine (Aralen): 500 mg every week, beginning one week pretravel and continuing until four weeks posttravel
Asia, South America (except Argentina and Paraguay), sub-Saharan Africa	Atovaquone/proguanil (Malarone): 250/100 mg every day, beginning one to two days pretravel and continuing until seven days posttravel or Mefloquine (Lariam): 250 mg every week, beginning one week pretravel and continuing until four weeks posttravel*
note: Risk (including drug-resistant strains) may be restricted to regions of some countries; targeted recommendations are available at http://www.cdc.gov/travel. *-Mefloquine is not recommended for travelers to western Cambodia and forested areas of Thailand-Cambodia and Thailand-Burma borders because of multidrug-resistant Plasmodium falciparum.

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