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29/12/2020 - Press release

High triglyceride and remnant cholesterol levels increase cardiovascular disease risk in high-risk patients

The work analysed data from 6,900 patients who participated in the PREDIMED study and were overweight or obese

A study that has just been published in the Journal of the American College of Cardiology shows that high levels of triglycerides (the most common type of fat in the body), as well as those of remnant cholesterol (in triglyceride-rich lipoproteins), increase the risk of suffering cardiovascular disease in high-risk patients, even if they take the usual treatment to control blood cholesterol levels. The work is authored by researchers from the Hospital del Mar Medical Research Institute (IMIM-Hospital del Mar), Hospital Clínic de Barcelona-IDIBAPS, and the CIBER on the Physiopathology of Obesity and Nutrition (CIBERObn). 

The study monitored 6,900 patients included in the PREDIMED study (Prevention with Mediterranean Diet) over a five-year period. The average age of the patients was 67, they were overweight or obese and, in almost half of the cases, they were suffering from diabetes. In other words, they had a high level of cardiovascular risk. They were also following treatments to control cholesterol (predominantly using statins). It has been demonstrated that, despite taking this medication, this group still suffers numerous cardiovascular episodes (such as heart attack and stroke). This risk is due to an increase in triglycerides and the lipoproteins that transport these in the blood. In cases of obesity and diabetes this phenomenon is amplified, since these pathologies delay the metabolism of triglycerides. This results in increased levels of triglyceride-carrying particles, which are also enriched with cholesterol (remnant cholesterol).

Image: Above, from left to right, Dra Montse Fitó and Dra Olga Castañer. Below, from left to right, Dr. Emili Ros and Dr. Emilio Ortega. Source: IMIM.

More risk with higher levels

The researchers have been able to prove, using blood samples from the participants, that both elements, remnant cholesterol and triglycerides, are directly related to increased cardiovascular risk in people who are highly predisposed to this, even if they keep their LDL cholesterol (low-density lipoprotein or bad cholesterol) levels under control, and independently of lifestyle and other cardiovascular risk factors. In fact, an increase of 10 mg/dl in triglyceride concentrations in the blood increases the risk of suffering a heart attack or other cardiovascular pathology by 4%. For remnant cholesterol, the same increase in concentrations elevates the risk up to 21%. In addition, "Individuals with a concentration of remaining cholesterol above 30 mg/dl (75% of the cohort), showed a significant increase in cardiovascular risk, despite maintaining optimal concentrations of LDL cholesterol", according to Dr. Olga Castañer, first author of the study and a researcher in the Cardiovascular Risk and Nutrition Research Group at the IMIM-Hospital del Mar and CIBERObn.

"The results of the study suggest that, for individuals who have a high cardiovascular risk and well-controlled LDL cholesterol, the next therapeutic targets could be triglycerides and, particularly, remnant cholesterol", indicates Dr. Montse Fitó, final author of the paper and coordinator of the Cardiovascular Risk and Nutrition Research Group at IMIM-Hospital del Mar and also a CIBERObn researcher. The greatest increase in risk related to remnant cholesterol can be attributed to mechanisms associated with plaque formation in the arteries and local inflammation, processes that can lead to plaque rupture and, consequently, a cardiovascular event.

For this reason, Dr. Emilio Ortega, one of the authors of the study, a physician at the Endocrinology and Nutrition Service at Hospital Clínic and a IDIBAPS and CIBERObn researcher, explains that "Our work offers the opportunity of proposing clinical trials to answer the question of whether remnant cholesterol and/or triglycerides should be the preferred therapeutic target in patients with high cardiovascular risk and adequate LDL cholesterol levels or, alternatively, whether this should still be reduced in order to decrease the risk of a first cardiovascular event." The study may have a direct impact, especially with respect to the clinical management of dyslipidemia (qualitative or quantitative disorder of lipids and lipoproteins in the blood) in patients with a high cardiovascular risk level. "These results suggest that, in the clinical management of dyslipidemia, it is important to achieve greater control of the entire lipid profile, including triglycerides and remnant cholesterol", explains Dr. Emilio Ros, an author of the study, a doctor in the Endocrinology and Nutrition Service at Hospital Clínic, and an IDIBAPS and CIBERObn researcher.

Reference article

Olga Castañer, Xavier Pintó, Isaac Subirana, Antonio J. Amor, Emilio Ros, Álvaro Hernáez, Miguel Ángel Martínez-González, Dolores Corella, Jordi Salas-Salvadó, Ramón Estruch, José Lapetra, Enrique Gómez-Gracia, Angel M. Alonso-Gomez, Miquel Fiol, Lluís Serra-Majem, Emili Corbella, David Benaiges, Jose V. Sorli, Miguel Ruiz-Canela, Nancy Babió, Lucas Tojal Sierra, Emilio Ortega, Montserrat Fitó, Remnant Cholesterol, Not LDL Cholesterol, Is Associated With Incident Cardiovascular Disease, Journal of the American College of Cardiology, https://doi.org/10.1016/j.jacc.2020.10.008.

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