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Triglycerides & Heart Disease-new study: Cream and Sugar Study sheds light on triglyceride interpretation
  August 28, 2011 Lisa Nainggolan

Paris, France - A new study may finally shed light on how to interpret triglyceride levels in patients with cardiovascular disease. In a novel trial, Dr Ulrich Laufs (Saarland University Hospital, Homburg, Germany) and colleagues examined-for the first time-metabolic status together with postprandial triglyceride levels to see whether the latter predicted cardiovascular events; investigators found that, in the overall study population, they did not.

However, postprandial triglycerides appeared to be an even stronger predictor of risk than fasting triglycerides in those with normal glucose levels, said Laufs, who presented the results of the Homburg Cream & Sugar Study (HCS) during a late-breaking clinical-trials session today at the European Society of Cardiology 2011 Congress.

In contrast, although those with diabetes or impaired glucose tolerance generally had higher triglycerides than those with normal glucose levels, neither postprandial nor fasting triglycerides were predictive of events in this patient group. "I would guess that, probably, lowering triglyceride is not important for everybody," Laufs told heartwire.

Discussant of the study, Dr Philip Barter (University of Sydney, Australia), praised Laufs and colleagues for their attempt "to address a complicated and confusing question. This is the first study to assess whether metabolic status has an impact on the ability of triglyceride levels to predict cardiovascular risk." He pointed out some limitations of the HCS, noting, "The results are provocative and, if real, have important clinical implications for identifying individuals in whom we do need to treat triglycerides."

But he added, "I don't understand why there is no prediction in those with impaired glucose tolerance or diabetes, so this finding does require confirmation. We cannot assume this is a proven case."

Confirmation will be labor-intensive, but is important

Although serum triglyceride concentrations have long been associated with the CVD risk, the extent of the relationship has been unclear and inconsistent, both Laufs and Barter said.

The results are provocative and if real, have important clinical implications for identifying individuals in whom we do need to treat triglycerides.

Usually, fasting triglycerides are assessed, but because triglycerides are affected by glucose and insulin, Laufs and colleagues also examined the feasibility of combined testing of postprandial glucose and triglycerides. This is the first prospective study to simultaneously assess the two measures in a representative cohort of patients with coronary artery disease (CAD), Laufs said.

In the HCS study, 514 participants with stable CAD ate an evening meal and then fasted overnight; fasting triglycerides were measured the following morning. Participants were then given a 250-mL cream drink containing 75 g of fat followed three hours later by a glucose drink (250 mL of water with 75 g of glucose). Those with known diabetes were only given the cream drink. Measurements taken included fasting and postprandial triglycerides, insulin concentrations, and glucose tolerance up to five hours after the cream drink. The primary end point was CVD and cardiovascular hospitalizations after 18 months of follow-up.

Laufs told heartwire that the cost of adding in the postprandial triglyceride test was minimal; in Germany, it worked out to less than $2 per patient.

In the total cohort, postprandial triglyceride concentrations did not correlate with the number of primary-end-point events, and while fasting triglycerides were found to be predictive, this association was lost in multivariate analysis, Laufs said.

In those with normal glucose tolerance, the hazard ratio for the primary end point was 3.10 (p=0.04) for those in the highest tertile of fasting triglycerides (compared with lowest), and 4.45 (p=0.02) for those in the highest tertile of postprandial triglycerides.

Commenting on the findings, Laufs observed: "It seems that glucose tolerance determines triglyceride pharmacokinetics," but he agreed with Barter that this finding requires confirmation in further studies.

Barter said several factors limit the conclusions that can be drawn from the study, including the relatively small sample size, the "soft" primary end point that included hospitalizations, and the short duration of follow-up and, consequently, small number of events.

He implored others to conduct confirmatory studies, observing that while it is "labor-intensive" to include glucose tolerance testing in epidemiologic studies, this is an important issue that he would encourage.

Laufs has received honoraria from AstraZeneca, Boehringer Ingelheim, Daiichi Sankyo, Essex, Merck Sharp & Dohme, Novartis, Roche, Sanofi, Servier, and Trommsdorff.

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