OVERVIEW
Hypertriglyceridemia is an abnormality of lipid metabolism in which plasma triglyceride levels are elevated and total cholesterol levels are normal.
Most of them have no obvious discomfort and are found during physical examination or when there are complications.
Related to genetics, disease, lifestyle, etc.
Diet, exercise, and medications all play a role in the treatment of this disease.
Definition
Hypertriglyceridemia is a pathological condition in which the serum triglyceride (TG) level is elevated above 1.70 mmol/L (millimoles per liter) and the total cholesterol (TC) level is normal (<5.18 mmol/L).
Hypertriglyceridemia is a type of dyslipidemia in which plasma triglycerides are found mainly in celiac microparticles (CM) and very low density lipoproteins (VLDL).
Chymotrypsin: the largest particle lipoprotein in the blood, the main component is triglyceride, accounting for nearly 90%, its density is very low, normal people fasting blood collection, serum in the absence of chymotrypsin. It can transport triglycerides and cholesterol from food to other tissues from the small intestine.
Very Low Density Lipoprotein (VLDL): Synthesized by the liver, VLDL can contain up to 55% triglycerides, and together with celiac disease, are collectively known as triglyceride-rich lipoproteins. Very low density lipoproteins transport triglycerides produced in the body to peripheral tissues, where they are hydrolyzed to release free fatty acids.
Pathogenesis
Hypertriglyceridemia is a common dyslipidemia in our population.
In recent years, the blood lipid level of China’s population has gradually increased, and the prevalence of dyslipidemia has increased significantly, with the overall prevalence of adult dyslipidemia reaching 40.40%.
The prevalence of hypertriglyceridemia in China is as high as 12.7%.
After statin treatment, there are still a large number of patients whose triglycerides do not reach the standard. According to the DYSIS-China study, 47.6% of patients taking statin drugs still have hypertriglyceridemia or low HDL; in very high-risk patients, the proportion is even higher than 74.2%.
Causes
Causes
Hypertriglyceridemia is associated with heredity, disease, lifestyle, medications, and other factors.
Genetic factors
Familial hypertriglyceridemia: caused by a single gene mutation, autosomal dominant inheritance is more common, family members can be concentrated for more than three consecutive generations of patients with the disease.
Disease factors
Diabetes mellitus: due to abnormal insulin secretion, etc., resulting in elevated triglyceride levels.
Kidney disease: due to increased synthesis of very low density lipoprotein (VLDL) and low density lipoprotein (LDL).
Hypothyroidism: often combined with elevated plasma triglyceride concentrations.
Pharmacologic factors
The use of glucocorticoids, high-dose beta-blockers and diuretics can also contribute.
Lifestyle
A high-fat, high-sugar diet can also cause elevated plasma triglyceride levels.
Alcohol consumption also has an effect on elevated plasma triglyceride levels.
People who are physically inactive and habitually sedentary have higher plasma triglyceride levels than those who are physically active.
Obesity: The production of very low density lipoproteins is markedly increased by the excessive hepatic synthesis of apolipoprotein B. The production of very low density lipoproteins is significantly increased by the hepatic synthesis of apolipoprotein B.
Age
An important factor affecting lipid levels, as plasma triglyceride levels increase with age.
Pathogenesis
The pathogenesis of hypertriglyceridemia is related to increased uptake of exogenous triglycerides or other related substances, increased endogenous triglyceride synthesis, and abnormalities in triglyceride transport and catabolism.
Increased uptake of exogenous triglycerides or other related substances: e.g. high intake of triglyceride-containing foods.
Increased endogenous triglyceride synthesis: e.g., increased synthesis of very low density lipoprotein in the liver.
Abnormal triglyceride transport and catabolism: e.g., abnormal transport and catabolism of celiac disease particles and very low density lipoproteins.
Symptoms
Major Symptoms
Most are asymptomatic and are often detected on physical examination or with complications.
Some patients with severe hypertriglyceridemia may present with a skin rash of yellow tumors.
It is a soft, flattened yellow spot that is slightly elevated and has a clear border with the surrounding normal skin.
The lesions are often located on the upper lid near the inner canthus and sometimes on the lower lid.
They can also be seen in the tendon areas, the extensor side of the body, and the palms of the hands.
Complications
People with elevated serum triglyceride levels have an increased risk of developing atherosclerosis, and a few cases of very severe hypertriglyceridemia can lead to acute pancreatitis.
Atherosclerosis
Atherosclerosis is the most common pathological change in cardiovascular and cerebrovascular system diseases, and the lesions mainly occur in coronary arteries, carotid arteries, intracranial arteries, renal arteries, limb arteries and so on.
Symptoms are related to the degree and location of the lesion, and may include chest pain, abdominal pain, limb pain, dizziness, etc., or may be asymptomatic.
Acute Pancreatitis
Acute abdominal pain: often occurs suddenly after a full meal or drinking alcohol, located in the middle and left upper abdomen or even the whole abdomen, can be colic or cutting pain.
Abdominal distension: often accompanied by abdominal pain.
Nausea and vomiting: Vomiting is often violent and frequent, and the vomit is mainly food, occasionally coffee-colored substances may also be vomited.
Other manifestations: fever, yellowing of the skin and sclera (commonly known as the whites of the eyes).
Consultation
Department of Medicine
Cardiovascular Medicine
Routine physical examination reveals elevated triglycerides, or symptoms such as yellow skin tumors, dizziness, headache, chest tightness, etc. Prompt medical consultation is recommended.
Endocrinology
Triglyceridemia can also be treated in the Department of Endocrinology.
Preparation for medical treatment
Consultation: Registration, Preparation of documents, Frequently asked questions
Consultation Tips
Patients with hypertriglyceridemia do not have obvious clinical symptoms and are often found during physical examination, so they need to consult a doctor in time to avoid the development of the disease.
Do not abuse drugs without doctor’s permission, so as to prevent drugs from affecting the relevant examinations and interfering with the diagnosis and treatment of the disease.
Preparation List
Symptom list
Pay special attention to the time of onset of symptoms, special manifestations, etc.
Have you had dizziness or headache recently?
Any other uncomfortable symptoms?
Medical History Checklist
Is there a family history of related medical conditions?
What is your diet? Is there any greasy diet, overeating?
Do you smoke or drink alcohol?
Have you had a recent physical examination? What are the results of the physical examination?
Any other diseases?
Checklist
Results of the last six months, which can be brought to the doctor’s office
Routine blood test
Blood biochemistry
Lipid Profile
Urine routine
Abdominal ultrasound
Liver and Kidney Function Tests
Thyroid Function Test
Medication List
Medications used in the last 3 months, if available, bring the box or package to the doctor’s office
Statin lipid regulators/lovastatin, simvastatin, atorvastatin
Cholesterol absorption inhibitors: Ezetimibe
Other lipid regulators: Probucol
Betas: Fenofibrate, Benzafibrate, Gemfibrozil
Diagnosis
Diagnosis is based on
The doctor confirms the diagnosis based on medical history, symptoms, and laboratory findings.
Medical History
Parents with hypertriglyceridemia.
May have history of diabetes, nephrotic syndrome, obesity, hypothyroidism etc.
Daily high-fat and high-sugar diet, low activity, etc.
May have a history of medications such as glucocorticoids, beta-blockers, diuretics, etc.
Symptoms
Most are asymptomatic, a few may have yellow tumors of the skin.
Laboratory Tests
Lipid profile
Including plasma or serum total cholesterol (TC), triglycerides (TG), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C), can understand whether the level of the above indexes is elevated or not, and provide a basis for confirming the diagnosis of hypertriglyceridemia.
Other tests
Other tests, including apolipoprotein A (Apo A1), apolipoprotein B (Apo B), and lipoprotein (a), are also clinically significant in predicting coronary artery disease.
Familial dyslipoproteinemia can be genetically diagnosed and associated genetic abnormalities can be seen.
Precautions
To ensure the stability of the test results, subjects should maintain a regular, more constant diet and stable weight for 2 weeks prior to the test.
Avoid strenuous exercise for 24 hours prior to the test. Fasting begins after 8:00 p.m. on the day before blood collection (small amounts of water may be consumed), and blood is collected the following morning or at 8:00 to 10:00 a.m.
Diagnostic Criteria
The diagnosis of hypertriglyceridemia was made using the criteria for appropriate levels of blood lipids and stratification of abnormalities set out in the Chinese Guidelines for the Prevention and Control of Dyslipidemia in Adults (Revised Edition, 2016). Hypertriglyceridemia is when all other indicators are normal and only serum triglycerides are higher than normal, i.e., ≥1.7 mmol/L.
Differential diagnosis
If a physical examination reveals elevated triglycerides, the physician may rule out the following conditions at the time of the visit.
Acute pancreatitis
Similarities: Elevated triglycerides.
Differences: Acute pancreatitis may present with abdominal pain, nausea, vomiting, etc. Pancreatic congestion and edema may be seen on ultrasound.
Hypothyroidism (hypothyroidism)
Similarities: elevated triglycerides.
Differences: Hypothyroidism is characterized by low metabolic symptoms such as fatigue, weight gain, abdominal distension, and slowness of movement. Thyroid function tests for hypothyroidism may show elevated serum thyroid stimulating hormone (TSH) and decreased thyroid hormones (T3 and T4).
Nephrotic syndrome
Similarities: elevated triglycerides.
Differences: Nephrotic syndrome may be characterized by massive proteinuria (>3.5 g/day) and hypoalbuminemia (<30 g/l).
Treatment
General treatment
The principle of treatment for hypertriglyceridemic patients depends on the degree of elevation of triglycerides and the level of overall cardiovascular risk. Lifestyle changes are the basis for the treatment of hypertriglyceridemia, and severe elevations of triglycerides (≥5.65 mmol/L) should be treated with pharmacologic therapy.
Regardless of whether drug therapy is chosen, lifestyle interventions must be adhered to, including rational diet, moderate activity, smoking cessation and alcohol restriction.
Medication
Betaine
May be the drug of choice for lowering triglyceride levels.
Common drugs: Fenofibrate tablets, micronized fenofibrate capsules, benzafibrate, gemfibrate and so on.
Effects: Can lower serum triglycerides and raise HDL cholesterol levels.
Adverse effects: Similar to statins, including hepatic, renal, and muscular toxicity.
Statins
Commonly used drugs: lovastatin, simvastatin, atorvastatin, resuvastatin and so on.
Effects: Mainly cholesterol-lowering, but also lowering serum triglyceride levels and mildly elevating HDL cholesterol levels.
Adverse effects: The most common are elevated transaminases, myalgia, myositis and rhabdomyolysis.
Precautions: Contraindicated in pregnant women, hepatic and renal dysfunction, immune myopathy, and hypersensitivity to statins.
Niacin
Also known as vitamin B3, an essential vitamin.
Commonly used drugs: slow-release dosage form.
Effects: In high doses it lowers total cholesterol, triglycerides, and LDL cholesterol, as well as elevating HDL cholesterol.
Dosage: Start with a small dose and increase gradually, take at bedtime.
Efficacy: 12 weeks of application may result in a 29% decrease in triglycerides and a 25% increase in HDL cholesterol.
Adverse effects: facial flushing, liver damage, hyperuricemia, hyperglycemia, and gastrointestinal discomfort.
Omega-3 fatty acids
Decreased triglyceride and very low-density lipoprotein levels by 45% and 50%, respectively, in patients with severe hypertriglyceridemia.
Adverse effects are rare.
Prognosis
Cure
Most patients with hypertriglyceridemia can achieve compliance with diet, lifestyle modification, and drug therapy.
A very small number of patients with genetic abnormalities still have very high triglyceride levels after diet and lifestyle improvement, and require long-term, or even lifelong, use of lipid-regulating drugs.
Harmfulness
Patients with hypertriglyceridemia may develop yellow tumors on the skin, which affects aesthetics.
It may increase the risk of cardiovascular disease and can lead to coronary heart disease, hypertension and other diseases.
Hypertriglyceridemia may affect the digestive system, and some patients may be at risk of pancreatitis.
Daily
Daily Management
Dietary management
Total daily fat intake should be minimized, and cooking oil should be less than 30g per day. n-3 polyunsaturated fatty acid rich foods (e.g. deep-sea fish, fish oils, vegetable oils) should be preferred for fat intake, and the following are the recommended intake of dietary fats and food sources.
Controlling the total amount of diet, limiting carbohydrate and fat intake, and increasing the intake of vegetables and high-quality proteins can reduce triglycerides by 20% to 50%.
Recommended Intake of Fat Types Food Sources
Saturated fat less than 7% of total calories High lipid levels or less than 7% in patients with coronary heart disease Meat, unskimmed dairy products (whole milk, cheese), artificially hydrogenated vegetable oils
Saturated fat
Less than 7% of total calories or less than 7% for those with high lipid levels or coronary heart disease
Meat, non-skimmed dairy products (whole milk, cheese), artificially hydrogenated vegetable oils
Polyunsaturated fat up to 10% of total calories Flaxseed oil, caraway seed oil, perilla oil, walnut oil
Polyunsaturated fats
10% of total calories
Flaxseed oil, caraway seed oil, perilla oil, walnut oil
20% of total calories from monounsaturated fats Canola oil, olive oil, nuts, avocado
Monounsaturated fats
20% of total calories
Canola oil, olive oil, nuts, avocado
Foods to reduce
Meat or meat products: Fatty beef, lamb, pork, ribs, offal (e.g., liver), sausage, etc.
Dairy and eggs: whole milk, whole yogurt, condensed milk, cream, margarine, cheese, ice cream, egg yolks (less than 3 a week).
Baked goods: pies, cakes, doughnuts, pastry, muffins, cookies, bread made with lots of eggs, etc.
Saturated fats and oils: chocolate, coconut oil, palm oil, lard.
Vegetables and fruits: vegetables and fruits prepared with butter, coconut.
Foods to choose
Meat: fish, chicken (without skin), lean beef, lamb, pork.
Dairy and eggs: skim or low-fat dairy products, cholesterol-free egg substitutes, egg whites (2 egg whites can replace 1 egg).
Baked goods: homemade foods made with unsaturated oils, whole grain breads, low-fat skittles, etc.
Unsaturated fats: olive oil, corn oil, sesame oil, soybean oil, sunflower oil.
Coarse grains: soybeans, corn, purple rice, sorghum, oats, buckwheat, bran, etc.
Others: nuts, fresh fruits and vegetables (apples, bananas, garlic, celery).
Life Management
Moderate Exercise
30 minutes of moderate-intensity exercise (brisk walking, stair climbing), etc. per day, at least 5 times per week.
Burn at least 200 kcal per exercise and maintain an appropriate body mass index (20.0-23.9).
For patients with atherosclerotic cardiovascular disease, the safety of exercise should be fully evaluated through exercise load tests under the guidance of a doctor to develop an exercise program.
Smoking cessation and alcohol restriction
Smoking cessation: complete cessation of smoking and effective avoidance of secondhand smoke inhalation.
Alcohol restriction: It is not recommended for those who do not drink alcohol, and for those who do drink alcohol, the daily alcohol intake should be limited to 30g (for men) and 20g (for women).
Follow-up review