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Atherosclerosis prevention for the next decade: risk assessment beyond low density lipoprotein cholesterol
1Department of Medicine, University of Toronto, Ontario.
Insights
High triglycerides and low HDL cholesterol, especially with abdominal obesity, significantly increase atherosclerosis and ischemic heart disease (IHD) risk. Comprehensive risk assessment beyond LDL cholesterol is crucial for effective IHD prevention.
Area of Science:
- Cardiovascular Medicine
- Metabolic Syndrome
- Atherosclerosis Research
Background:
- Elevated plasma cholesterol is a known cause of atherosclerosis and ischemic heart disease (IHD).
- However, many individuals with IHD have desirable cholesterol levels, indicating other risk factors are involved.
- New metabolic risk factors are being identified to improve IHD risk assessment and management.
Purpose of the Study:
- To review evidence linking hypertriglyceridemia, low HDL cholesterol, and abdominal obesity to increased IHD risk.
- To highlight the atherogenic potential of this metabolic phenotype.
- To advocate for comprehensive risk reduction strategies beyond LDL cholesterol management.
Main Methods:
- Review of existing scientific literature and evidence.
- Analysis of the association between hypertriglyceridemia, HDL cholesterol, abdominal obesity, and IHD.
- Examination of related metabolic factors like insulin resistance and LDL particle size.
Main Results:
- Hypertriglyceridemia, particularly with low HDL cholesterol and abdominal obesity, constitutes a highly atherogenic phenotype.
- This phenotype is often associated with elevated apolipoprotein B, insulin resistance, and small, dense LDL particles, further increasing IHD risk.
- Assessing plasma triglycerides, HDL cholesterol, and abdominal obesity offers a cost-effective approach to identifying high atherogenic risk.
Conclusions:
- A therapeutic strategy incorporating triglyceride, HDL cholesterol, and abdominal obesity assessment is recommended for comprehensive IHD risk reduction.
- Focusing solely on LDL cholesterol is insufficient for managing IHD.
- Adopting integrated risk reduction strategies is essential to lower the incidence of IHD.
Abstract:
Several lines of evidence have demonstrated that increased plasma cholesterol plays a primary role in the etiology of atherosclerosis and ischemic heart disease (IHD). Our ability to manage IHD adequately based on plasma cholesterol or low density lipoprotein (LDL) cholesterol concentrations is challenged, however, by evidence suggesting that a significant proportion of individuals with IHD or who will eventually develop IHD have desirable cholesterol concentrations. These observations have generated much interest in the scientific community, with the resultant identification of new metabolic risk factors that may help, in the future, to improve our ability to reduce the risk of IHD adequately. This review presents evidence that hypertriglyceridemia, particularly when associated with reduced high density lipoprotein (HDL) cholesterol concentrations and abdominal or visceral obesity, is a highly atherogenic phenotype, one that requires aggressive risk reduction management. Hypertriglyceridemia is frequently associated with elevated plasma apolipoprotein B concentrations, with states of hyperinsulinemia or insulin resistance and with small, dense LDL particles, which may all contribute to increase the risk of IHD further. This evidence suggests that a therapeutic strategy based on the assessment of plasma triglyceride concentrations, along with HDL cholesterol levels and abdominal obesity, may be a cost effective approach to assessing the high atherogenic risk of visceral obesity and insulin resistance. We can no longer afford to focus our attention exclusively on the detection and management of elevated LDL cholesterol concentrations, and need to adopt comprehensive risk reduction strategies in order to lower the incidence of IHD.