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Dr. Philip Barter,
Dr. Ulrich Laufs
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Presenter | see Discussant report
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Background: Risk prediction with fasting serum triglycerides (TG) in high cardiovascular risk patients with normal and impaired glucose tolerance remains uncertain. The role of postprandial serum triglycerides as a risk modifier in secondary prevention is unknown. Methods: An oral triglyceride and glucose tolerance test was developed to obtain standardized measurements of postprandial TG kinetics in 514 consecutive patients with angiographically confirmed coronary artery disease. Follow-up was 18 months and the primary outcome was the composite of cardiovascular death and cardiovascular hospitalization. Results: Postprandial TG kinetics depended on glucose tolerance: Patients with normal glucose tolerance had lower fasting TG (N=126, 108±42mg/dl) and a lower absolute postprandial TG increase compared to patients with pathologic glucose metabolism (N=388, fasting TG 172±157mg/dl) whereas the mean relative TG increase was similar. In the total cohort and in patients with impaired glucose tolerance, postprandial TG did not correlate with the number of primary endpoint events. Fasting TG were predictive in univariate- but not in multivariable analysis. In patients with normal glucose metabolism, fasting TG as well as postprandial TG kinetics (area under the curve and the relative postprandial increase) predicted the occurrence of the primary outcome. They remained independent predictors after adjustment for baseline characteristics, metabolic parameters and cardiovascular risk factors (fasting TG >150mg/dl vs. <106mg/dl: HR 3.10 (CI 1.06-9.06), p=0.04; relative postprandial TG increase >210% vs. <171%: HR 4.45 (CI 1.33-14.91), p=0.02). Conclusions: Fasting and postprandial triglyceride values independently predict cardiovascular events in patients with coronary artery disease and normal glucose tolerance. Funded by the Deutsche Stiftung für Herzforschung and the Universität des Saarlandes (HOMFOR), ClinicalTrials.gov number: NCT00628524. Discussant | see Presenter abstract
This study addressed the controversial issue of the ability of plasma triglyceride levels to predict cardiovascular risk. Previous analyses of very large databases have drawn two conclusions: (i) The fasting triglyceride level is NOT predictive of future cardiovascular events after adjustment for other factors (1). (ii) In contrast, the non-fasting triglyceride level is a significant predictor of future cardiovascular events, independent of other risk factors (2). The study presented by Laufs and collaborators asked the question: is the relationship between plasma triglyceride and cardiovascular risk influenced by the glucose metabolic status of the patient? The study included 514 patients with clinically stable coronary artery disease, of whom 24.5% had normal glucose tolerance, 29.2% had impaired glucose tolerance and 46.3% had type 2 diabetes. Participants were given fat and glucose tolerance tests on entry to the study and were followed for 18 months. The primary outcome was a composite of cardiovascular death and cardiovascular hospitalization. Main findings In the total cohort, neither the fasting nor the postprandial triglyceride level predicted cardiovascular outcomes after adjustment for other factors. This was also the case in the three quarters of the cohort who had impaired glucose tolerance or diabetes. In marked contrast, however, in the one quarter of participants who had normal glucose tolerance, both the fasting and postprandial triglyceride levels were predictive of the risk of having a cardiovascular event over the subsequent 18 months, independent of other risk factors. Limitations of the study The relatively small sample size, relatively short follow-up and consequent small number of cardiovascular events, combined with the fact that the cardiovascular endpoint was rather “soft”, limits the conclusions that can be drawn. In addition, there is no indication of the mechanism responsible for what, if real, is a very interesting finding Strength of the study This is the first study designed to assess whether glucose metabolic status impacts on the ability of triglyceride levels to predict cardiovascular risk. The results are provocative and, if real, have potentially important clinical implications. References 1. The Emerging Risk Factors Collaboration. JAMA 2009;302:1993–2000 2. Bansal S et al., Women’s Health Study, JAMA 2007;298:309-316
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