• Cardiovascular Diseases
• Chemistry, Clinical
• Diagnostic Techniques and Procedures
• LIPIDS
• LIPOPROTEINS

The diagnosis and specific management of hypertriglyceridaemia (HTG) is overshadowed and often ignored in favour of low-density lipoprotein cholesterol (LDL-C).1 General practitioners will often not request it; partly because most cardiovascular disease (CVD) risk calculators do not require it, and partly because of the potential need for patients to be fasting. So why bother? The answer is twofold—accurate diagnosis and assessment of risk (of CVD and of acute pancreatitis (AP)).

Wierzbicki et al 2 discuss the diagnosis and management of HTG in a best practice update. Classically, the full traditional profile consisted of total cholesterol, high-density lipoprotein cholesterol (HDL-C), triglyceride (TG) and a calculated LDL-C based on the Friedewald equation, which involved a fasting sample. Recent guidelines have moved away from recommending fasting lipid profiles based on large observational cohort studies (Danish) showing that, for most patients, fasting has little impact on lipid measurement.3 TG levels>4.5 mmol/L, the upper limit of validity of the Friedewald equation, were found in 3%–5% of non-fasting individuals in populations.1 There are two exceptions—one where an accurate LDL is acquired (usually calculated) and the other where TG is >10 mmol/L. A recently published meta-analysis has highlighted the use of non-HDL-C or apoB as superior metrics at least for assessing CVD risk.4 Part of this relates to evidence suggesting that some cholesterol in LDL particles is replaced by TGs, which makes the amount of cholesterol in LDL-C, an unreliable marker of LDL particle number.

It must be remembered that even with mild HTG>4.5 mmol/L, many HDL-C and indeed direct LDL assays become less reliable, potential affecting CVD risk and treatment decisions.5 In the presence of HTG over 10 mmol/L, the proportion of cholesterol, which is in triglyceride-rich lipoproteins (TRLs), will be raised, and the correlation between atherogenic potential and total cholesterol/HDL-C (commonly used in CVD …