2 Hyperlipidemia

Suggested citation: Endocrine Society. Endocrine Facts and Figures: Cardiovascular and Lipids. First Edition. 2016.

Hyperlipidemia is defined as elevated levels of various lipids in the bloodstream. This section will focus on hypercholesterolemia and hypertriglyceridemia, both of which constitute major risk factors for CVDs.

Hypercholesterolemia and Hypertriglyceridemia

Hypercholesterolemia is usually defined by the presence of one, or more of the following lipid abnormalities: elevated total cholesterol (TC) (200-239 mg/dL considered borderline-high risk, or ≥240 mg/dL considered high risk); elevated low-density lipoprotein cholesterol (LDL-C,>130 mg/dL); and elevated non-high density lipoprotein cholesterol (HDL-C, ≥145 mg/dL).4,11,12 Hypertriglyceridemia is a lipid abnormality characterized by elevated serum triglyceride (TG) levels (≥150 mg/dL), and is also a risk factor for CVD.13

2.1 Prevalence and Incidence

According to a 2012 report, 42.2% of US adults are at moderate risk of developing hypercholesterolemia (TC ≥200 mg/dL), 13.1% are at high risk (TC ≥240 mg/dL) (Table 4), and another 6.2% of cases are thought to be undiagnosed.6

Table 4: Prevalence of elevated total cholesterol and hypercholesterolemia in the United States.
Data source Population Category Prevalence (%)
NHANES 2009-2012 (extrapolated for 2012) US, adults, age ≥20 years Elevated total cholesterol (TC ≥200 mg/dL) 42.2
Hypercholesterolemia (TC ≥240 mg/dL) 13.1
Note: NHANES defines adult cholesterol levels ≥240 mg/dL as poor, and 200-239 mg/dL as intermediate.

Source: Mozaffarian et al. 20156

 

In 2008, a study of over 100,000 medical records of members of Kaiser Permanente Northwest, reported that approximately 36% of US adults presented with TG levels (≥150 mg/dL) that may lead to hypertriglyceridemia (Table 5).

Table 5: Prevalence of cardiovascular and lipid disorders in the United States.
Data source Population Method Hypertriglyceridemia Prevalence (%)
Members of Kaiser Permanente Northwest, 2008 US, adults (age >e;18 years) (n=108,324) Observational cohort study of electronic medical records Borderline-high risk (TG 150-199 mg/dL) 16.4
High risk TG 200-499 mg/dL) 18.0
Severe hypertriglyceridemia TG ≥500 mg/dL) 1.5
Abbreviations: TG, triglycerides.

Source: Nichols et al., 20118

 

2.2 Demographic Differences

The risk of developing hypercholesterolemia or hypertriglyceridemia is determined by a number of factors, including sex, race/ethnicity, age, weight classification status, education, healthcare, geography, and comorbidities.11,14

Table 6 summarizes data on sex differences in the prevalence of risk factors associated with hypercholesterolemia in US adults, children and adolescents. In brief, when assessing TC levels, females show a higher prevalence of the disease than their male counterparts, independently of age. These sex differences in hypercholesterolemia have been attributed to lower ideal physical activity in females (44%) than males (67%).15 Interestingly, a Minnesota-based study, found the prevalence of hypercholesterolemia (TC ≥200 and ≥240 mg/dL) to be lower in females than males, presumably due to better regional education and healthcare among females.14 On the contrary, males show a higher prevalence of elevated LDL-C and depressed HDL-C levels (Table 6).


Table 6: Sex differences in risk factors associated to hypercholesterolemia the United States.
Lipid profile Data source Population Lipid level Prevalence (%) Reference
Total Males Females
TC* NHANES 1999-2000

 

US, adults, age ≥20 years (n=4,148)

 

TC ≥200 mg/dL 50.5 49.7 51.1 Ford et al. 200316
TC ≥240 mg/dL 17.8 16.7 18.7
NHANES 2011-2012 US, adults, age ≥20 years (n=3469) TC ≥200 mg/dL NR NR NR Carroll et al. 201317
TC ≥240 mg/dL 12.9 11.1 14.4
 

Minnesota Heart Survey (MHS) 2000-2002

 

US, adults, age 25-84 years (n=1,352) TC ≥200 mg/dL 50.0 54.9 46.5 Arnett et al. 200514
TC ≥240 mg/dL 20.0 23.9 17.3
NHANES 2005-2010 US, children, age 12-19 years (n=4,673) TC 170-199 mg/dL 25 20 27 Shay et al. 201315
TC ≥200 mg/dL 8 8 8
NHANES 2011-2012 US children, age 8-17 years (n=1,482) TC ≥200 mg/dL 7.8 NR NR Kit et al.201518
LDL-C** NHANES 1999-2004 US, adults, age ≥20 years (n=1,628) LDL-C 25.3 29.9 21.1 Hyre et al. 20075
NHANES 2009-2012 US, adolescents age 12-19 years LDL-C NR 7.1 7.4 Mozaffarian et al. 20156
HDL-C NHANES 2011-2012 US, adults, age ≥20 years, (n=3,469) HDL-C ≤40 mg/dL 17.0 26.4 9.0 Carroll et al. 201317
NHANES 2011-2012 US, children and adolescents age 8-17 years (n=1,482) HDL-C ≤40 mg/dL 12.8 NR NR Kit et al. 201518

Note: *, The American Heart Association defines Intermediate risk of hypercholesterolemia TC ≥200 mg/dL in adults, or >e;170 mg/dL in children and adolescents; high risk as TC ≥240 mg/dL in adults or ≥200 mg/dL in children and adolescents.19; ** High LDL-C levels warranting therapeutic lifestyle changes and consideration of lipid-lowering therapy are specified by the National Cholesterol Education Program Adult Treatment Panel–III guidelines as ≥100 mg/dL for patients with coronary heart disease (CHD) and/or CHD risk equivalent(s). For patients without CHD or risk equivalent, high LDL-C is defined as LDL-C levels ≥130 mg/dL for patients with two or more CHD risk factors and a 10-year CHD risk of 10-20%, ≥160 mg/dL for patients with two or more CHD risk factors and a 10-year CHD risk <10%, and ≥190 mg/dL for patients with 0-1 CHD risk factors. A person with high LDL-C is defined as having LDL-C levels stated above, or if taking cholesterol-lowering medication.5
Abbreviations: NR, not reported.

Hypercholesterolemia due to elevated TC levels does not increase linearly with age. In fact, NHANES 1999-2000 data showed a peak in TC levels between 55-64 years (37.4%) in females but in a younger age group (45-54 years) in males (22.9%).16

Hypertriglyceridemia affects approximately a third of the US adult population. However, the severe form (TG ≥500 mg/dL) is rare, affecting less than 2% of the US population.20,21 A breakdown of the TG levels in a 2001-2006 NHANES study of US adults (n=5,680, age ≥20 years) extrapolated that while 14.2% of the US population had borderline-high TG levels (150-200 mg/dL), 16.3% had high TG levels (200 to <500 mg/dL), 1.7% had severe levels (500-2,000 mg/dL), and 0.0004% had very severe TG levels (>2,000 mg/dL).22

In addition, NHANES data indicates that hypertriglyceridemia is more common in males than females, regardless of age (Table 7).

Table 7: Prevalence of hypertriglyceridemia by sex in the United States.
Data source Population Level of Hypertriglyceridemia Prevalence (%) Reference
Total Males Females
NHANES 1994-2004 US adults, age ≥20 years n=5,610) Hypertriglyceridemia (TG ≥150 mg/dL) 33.1 36.7 29.6 Ford et al. 200920
Hypertriglyceridemia (TG ≥200 mg/dL) 17.9 21.5 14.4
Severe hypertriglyceridemia (TG ≥500 mg/dL) 1.7 2.8 0.8
Very severe hypertriglyceridemia (TG ≥1000 mg/dL) 0.4 NR NR
NHANES 1999-2006 US, adolescents, age 12-19 years (n=270) Hypertriglyceridemia (TG ≥150 mg/dL) 10.2 11.4 8.8 Centers for Disease Control and Prevention. 201023
NHANES 2009-2012 US, adolescents, age 12-19 years Hypertriglyceridemia (TG ≥150 mg/dL) NR 10.0 6.5 Mozaffarian et al. 20156

Abbreviations: TG, triglycerides; NR, not reported.

Elevated triglyceride levels in the US population increase with age to peak between 40-59 years of age, with little change thereafter (Table 8).

Table 8: Elevated Triglyceride levels (≥150 mg/dL) by age in the United States.
Data source Population Age Prevalence (%)
NHANES 2009-2012 US, adults, age ≥20 years (n=4,881) 20-39 years 19.9
40-59 years 28.8
>e;60 years 28.2

Source: Carroll et al. 20153

Several US studies examining lipid abnormalities by race/ethnicity and sex have reported elevated TC and depressed HDL-C level to be highest in Hispanic/Latinos and lowest in blacks (Table 9).17 In addition, elevated LDL-C is reported to be highest in whites and lowest in Mexican/Americans (Table 9).5


Table 9: Prevalence of hypercholesterolemia and hypertriglyceridemia in adults by race/ethnicity in the United States.
Lipid disorder Data source Population Category/Ethnicity Prevalence (%) Reference
Hypercholesterolemia NHANES 2011-2012 US, adults, age ≥20 years (n=3,469) TC ≥240 mg/dL Carroll et al. 201317
White (NH) 13.5
Black (NH) 9.8
Asian (NH) 10.3
Hispanic 14.2
NHANES 1994-2004 US, adults, age >e;20 years (n=1,628) LDL-C ≥130 mg/dL Hyre et al. 20075
White (NH) 26.9
Black (NH) 17.2
Mexican-Americans 16.5
NHANES 2011-2012 US, age ≥20 years (n=3,469) HDL-C Carroll et al. 201317
White (NH) 17.1
Black (NH) 12.7
Asian (NH) 14.3
Hispanic 21.8
Hypertriglyceridemia NHANES 1999-2004 US, adults, age ≥20 years (n=5,610) TGs ≥150 mg/dL Ford et al. 200920
White (NH) 35.3
Black (NH) 16.3
Mexican-Americans 37.9

Abbreviations: TC, total cholesterol; LDL-C low-density lipoprotein cholesterol; NH, non-Hispanics.

Risk factors for hypercholesterolemia and hypertriglyceridemia have been declining in the last two to three decades in children, adolescents, and adults (Table 10). The favorable changes in lipid levels in the US over time are suggested to be due to a combination of factors, including healthier diet and lifestyles and increase in the use of statin monotherapy.3


Table 10: Declining trends in risk factors for hypercholesterolemia and hypertriglyceridemia in the United States.
Lipid disorder Data source Population Lipid Profile Prevalence (%) Reference
Hypercholesterolemia NHANES 1976-1980 to 2007-2010 US, adults, age ≥20 years (n=7,044) 1976-1980 2007-2010 Kuklina et al. 200921
LDL-C* 59.5 27
NHANES 1999-2000 to 2011-2012 US, children and adolescents, age 8-17 years (n=1,482) 1999-2000 2011-2012 Kit et al. 201518
TC (≥200 mg/dL) 10.6 7.8
HDL-C (≤40 mg/dL) 17.9 12.8
non-HDL-C (≥145 mg/dL) 13.6 8.4
Hypertriglyceridemia NHANES 2001-2004 to 2009-2012 US, adults, age ≥20 years (n=4,115 for 2001-2004; n=4,881 for 2009-2012) 2001-2004 2009-2012 Carroll et al. 20153
TG (≥150 mg/dL) 33 25

Note: *, High LDL-C ≥100 mg/dL for patients with coronary heart disease (CHD) and/or CHD risk equivalent(s), ≥130 mg/dL for patients with two or more CHD risk factors and a 10-year CHD risk of 10-20%, ≥160 mg/dL for patients with two or more CHD risk factors and a 10-year CHD risk <10%, and ≥190 mg/dL for patients with 0-1 CHD risk factors. A person with high LDL-C is defined as having LDL-C levels stated above or if taking cholesterol-lowering medication.5

Geographical differences in the prevalence of hypercholesterolemia have also been reported in the US. A 2009 household survey of 9,612 adults (age ≥20 years) in a rural region in Upstate New York, (adjusted for age, sex, and education) found male farmers had significantly lower prevalence of hypercholesterolemia (odds ratio, OR, 0.7) than rural non-farm residents, but not lower prevalence of heart disease or stroke. Although the farmers had worse health behaviors such as screening, vaccinations, regular health care provider; the lower hypercholesterolemia rates were presumably due to lower rates of smoking (OR 0.6) and higher physical labor (OR 2.61).24

2.3 Life Expectancy and Mortality

According to the Centers for Disease Control and Prevention (CDC), the death rate in the US from CVDs declined by 29% from 1999 (30.3%) to 2013 (23.5%); however, CVDs remain the number one cause of mortality in the US, accounting for 611,105 of the 2,596,993 all-cause deaths in 2013.25 The declining death rate reflects favorable changes in the lipid levels in the US (as shown in Demographic Differences section above). Data from NHANES 1988-1994 (n=16,573) and 2007-2010 (n=11,766), in US adults, showed favorable decreases, over the 22-year time period, in serum levels of TC (206 to 196 mg/dL), LDL-C (129 to 116 mg/dL), non-HDL-C (155 to 144 mg/dL) and TGs (118 to 100 mg/dL), as well as favorable increases in HDL-C (50.7 to 52.5 mg/dL) and the use of lipid lowering medication (3.4% to 15.5%).26

2.4 Key Trends and Health Outcomes

Based on analysis of data collected in the crosssectional NHANES 1996 to 2006, the prevalence of hypercholesterolemia in US adults remained stationary from 1999 (53.2%) to 2006 (56.1%) (Table 11).2 In addition, only 50% of patients at borderline high risk were aware of their elevated cholesterol levels, and the condition was controlled by medications in fewer than 20%.


Table 11: Prevalence of checks, awareness, treatment, and control of hypercholesterolemia in the United States.
Data source Population Hypercholesterolemia Prevalence (%)
NHANES 1999 to 2006 US, adults age ≥20 years, unadjusted (n=18,053) TC ≥200 mg/dL 1999 2006
Cholesterol checked 68.6 74.8
Awareness of condition 42.0 50.4
Condition treated 39.1 54.4
Condition controlled 7.2 17.1
TC ≥240 mg/dL 1990 2006
Awareness of condition 65.4 74.6
HDL-C (≤40 mg/dL) 17.9 12.8
Condition treated 55.7 70.9
Condition controlled 27.6 44.2

Source: Ford et al. 20102

Analysis of NHANES data from 1999 to 2004 showed a gradual increase in the use of cholesterol-lowering medication and in improvements in controlling hypercholesterolemia to the target lipid levels with medication (Table 12).


Table 12: Lipid-lowering treatments for hypercholesterolemia in the United States.
Data source Population Treatment Prevalence (%)
NHANES 1999-2000 US, adults, age ≥20 years (n=1,770) Statin use (LDL-C in statin users: 119 mg/dL) 19.6
Control target of LDL-C achieved* 49.7
NHANES 2001-2002 US, adults, age ≥20 years (n=2,094) Statin use (LDL-C in statin users: 112 mg/dL) 27.3
Control target of LDL-C achieved* 67.4
NHANES 2003-2004 US, adults, age ≥20 years (n=1,911) Statin use (LDL-C in statin users: 100.7 mg/dL) 35.9
Control target of LDL-C achieved* 77.6

Source: Mann et al. 200827

Note: *, National Cholesterol Education Program Adult Treatment Panel –III guidelines for LDL-C control recommend the following targets: <100 mg/dL, years, respectively.5

A decrease in the prevalence of CVDs in the last two decades is partially attributed to increased use of lipidlowering drugs. Key findings from NHANES 2003 to 2012 in adults age >40 years showed a steady increasing trend from 20% to 28% in the use of cholesterol lowering drugs, and from 18% to 26% in the use of statins. In subjects with hypercholesterolemia, 54% were taking cholesterollowering medications in 2012.28

Although statins lower vascular morbidity and mortality in patients with hyperlipidemia, 10-15% of patients reported experiencing increased incidence of myalgia.29 In fact, statin intolerance was reported in 5-20% of patients, and discontinuation of treatment was common, especially in patients on high-intensity statins.29 Alternative therapies under investigation include PCSK9 inhibitors, which prevent the binding of PCSK9 to the LDL receptor. PCSK9 inhibitors appear to have milder side-effects than statins, although further data on safety, morbidity, and mortality are still pending from long-term clinical trials.29 Importantly, the FDA recently approved the use of PCSK9 inhibitors alirocumab and evolocumab in July and August 2015 respectively. While hypertriglyceridemia (TG ≥150 mg/dL) is common in the US population, the use of available prescription medications is low, as highlighted by a 5-year crosssectional study (Table 13).


Table 13: Percentage of hypertriglyceridemia patients receiving treatment in the United States.
Data source Population Triglyceride Levels Prevalence (%) Percentage of patients using 1 of 3 hypertriglyceridemia treatments (fenofibrate, gemfibrozil, or niacin)
NHANES 1999-2004 US adults, age ≥20 years (n=5,610) ≥150 mg/dL 33.1 2.6
≥200 mg/dL 17.9 3.6

Source: Ford et al. 200920

Therapeutic options in patients with mild-moderate hypertriglyceridemia (TG 150-500 mg/dL) include the use of statins to reduce levels of LDL-C and TGs, and the risk of CVDs. A recent retrospective cohort analysis also suggested decreased incidence of pancreatitis in association with statin use30,but these patients are generally not at high risk of pancreatitis, unlike those with severe hypertriglyceridemia (>500 mg/dL), who may additionally require treatment with long-chain omega-3 fatty acids, fibrates or niacin.31 Currently available therapies for hypertriglyceridemia are highlighted in Table 14.


Table 14: Health outcomes of lipid-lowering therapies for treatment of hypertriglyceridemia in the United States.
Data source Population Treatment Outcome Reference
Randomized, doubleblinded, crossover design, hospital US, adults age 19-59 years, Moderately hypertriglyceridemic and modestly hypercholesterolemic, normal LDL (n=11; 8 male, 3 female) Fenofibrate TG reduced by 45%, TC reduced by 14%, no changes in HDL or LDL Capell et al. 200332
Multinational, double-blind, randomized, out-patient study-EVOLVE trial 2011-2012 US adults, age ≥18 years, 3:1 ratio male:female, severe hypertriglyceridemia, TG ≥500-Omega-3 carboxylic acids (OM3-CA)TG reduced by 25.5-30.9%Kastelein et al. 201433
Retrospective cohort study 2006-2012, integrated healthcare system US, adults, age ≥18 years, TG 200-500 mg/dL (n=707,236) Simvastatin or atorvastatin Statins reduced the risk of acute pancreatitis: incidence rate ratio RR= 0.6 or when adjusted RR=0.29 Wu et al. 201530
Randomized, controlled, double-blind 6-week trial US, mean age 60.8 years, 95.3% used a statin, TG≥200 mg/dL (n=647) Omega-3 carboxylic acids (OM3-CA) TG reduced by 14.6-20.6% Dunbar et al. 201534
Placebo-controlled study US, severe hypertriglyceridemia, TG>e;00 mg/dL Omega-3 carboxylic acids (OM3-CA) TG reduced by 25-30% Zhao et al. 201535

References

1. World Health Organization. Cardiovascular diseases (CVDs) Fact sheet N°317 [webpage]. 2015; http://www.who.int/mediacentre/factsheets/fs317/en/.
2. F ord ES, Li C, Pearson WS, Zhao G, Mokdad AH. Trends in hypercholesterolemia, treatment and control amongUnited States adults. Int, J. Cardiol. 2010;Apr 15; 140(2):226-235.
3. C arroll MD, Kit BK, Lacher DA. Trends in Elevated Triglyceride in Adults: United States, 2001-2012. NCHS DataBrief 2015; http://www.cdc.gov/nchs/data/databriefs/db198.htm. Accessed September 2015.
4. T óth PP, Potter D, Ming EE. Prevalence of lipid abnormalities in the United States: The National Health and NutritionExamination Survey 2003–2006. Journal of Clinical Lipidology. 2012;6(4):325-330.
5. Hyre AD, Muntner P, Menke A, Raggi P, He J. Trends in AT P-III-Defined High Blood Cholesterol Prevalence,Awareness, Treatment and Control Among U.S. Adults. Annals of Epidemiology. 2007;17(7):548-555.
6. M ozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, de Ferranti S, Després J-P, FullertonHJ, Howard VJ, Huffman MD, Judd SE, Kissela BM, Lackland DT, Lichtman JH, Lisabeth LD, Liu S, Mackey, RH, Matchar DB, McGuire DK, Mohler ER, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Willey JZ, Woo D, Yeh RW, Turner MB. Heart Disease and Stroke Statistics—2015 Update: A Report From the American Heart Association. Circulation. 2015;131(4):e29-e322.
7. Heidenreich PA, Trogdon JG, Khavjou OA, Butler J, Dracup K, Ezekowitz MD, Finkelstein EA, Hong Y, JohnstonSC, Khera A, Lloyd-Jones DM, Nelson SA, Nichol G, Orenstein D, Wilson PWF, Woo YJ. Forecasting the future of
cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation.2011;123(8):933-944.
8. N ichols GA, Arondekar B, Garrison LP, Jr. Patient characteristics and medical care costs associated withhypertriglyceridemia. American Journal of Cardiology. 2011;Jan 15;107(2):225-229.
9. N ichols GA, Arondekar B, Jacobson TA . Hospital use and medical care costs up to 5 years after triglyceridelowering among patients with severe hypertriglyceridemia. Journal of Clinical Lipidology. 2012;6(5):443-449.
10. T oth PP, Grabner M, Ramey N, Higuchi K. Clinical and economic outcomes in a real-world population of patientswith elevated triglyceride levels. Atherosclerosis. 2014;237(2):790-797.
11. D ai S, Yang Q, Yuan K, Loustalot F, Fang J, Daniels SR, Hong Y. Non-high-density lipoprotein cholesterol:
distribution and prevalence of high serum levels in children and adolescents: United States National Health and Nutrition Examination Surveys, 2005-2010. J ournal of Pediatrics. 2014;Feb;164(2):247-253.
12. A ndersson C, Lyass A, Vasan RS, Massaro JM, D’Agostino RB, Sr., Robins SJ. Long-term risk of cardiovascular events across a spectrum of adverse major plasma lipid combinations in the Framingham Heart Study. American Heart Journal. 2014;Dec;168(6):878-883.
13. Pejic RN, Lee DT. Hypertriglyceridemia. The Journal of the American Board of Family Medicine. 2006;19(3):310-316.
14. A rnett DK, Jacobs DR, Luepker RV , Blackburn H, Armstrong C, Claas SA. Twenty-Year Trends in Serum Cholesterol, Hypercholesterolemia, and Cholesterol Medication Use: The Minnesota Heart Survey, 1980–1982 to 2000–2002. Circulation. 2005;112(25):3884-3891.
15. Shay CM, Ning H, Daniels SR, Rooks CR, Gidding SS, Lloyd-Jones DM. Status of cardiovascular health in US adolescents: prevalence estimates from the National Health and Nutrition Examination Surveys (NHANES) 2005- 2010. Circulation. 2013;Apr 2;127(13):1369-1376.
16. F ord ES, Mokdad AH, Giles WH, Mensah GA. Serum Total Cholesterol Concentrations and Awareness, Treatment, and Control of Hypercholesterolemia Among US Adults: Findings From the National Health and Nutrition Examination Survey, 1999 to 2000. Circulation. 2003;107(17):2185-2189.
17. C arroll MD KB, Lacher DA, Yoon SS. Total and high-density lipoprotein cholesterol in adults: National Health and Nutrition Examination Survey, 2011-2012. NCHS Data Brief. 2013; Oct.(132):1-8.
18. Kit BK, Kuklina E, Carroll MD, Ostchega Y, Freedman DS, Ogden CL. Prevalence of and trends in dyslipidemia and blood pressure among US children and adolescents, 1999-2012. JAMA Pediatrics. 2015;Mar;169(3):272-279. © 2015 The Endocrine Society. All rights reserved. ENDOCRINE SOCIETY | 11
19. L loyd-Jones DM, Hong Y, Labarthe D, Mozaffarian D, Appel LJ, Van Horn L, Greenlund K, Daniels S, Nichol G, Tomaselli GF, Arnett DK, Fonarow GC, Ho PM, Lauer MS, Masoudi FA , Robertson RM, Roger V, Schwamm LH, Sorlie P, Yancy CW, Rosamond WD, Committee AHASPTFaS. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond. Circulation. 2010;Feb 2;121(4):586-613.
20. F ord ES, Li C, Zhao G, Pearson WS, Mokdad AH. Hypertriglyceridemia and its pharmacologic treatment among US adults. Archives of Internal Medicine. 2009;169(6):572-578.
21. Kuklina EV, Yoon PW, Keenan NL. Trends in high levels of low-density lipoprotein cholesterol in the United States, 1999-2006. Journal of the American Medical Association. 2009;Nov 18;302(19):2104-2110.
22. C hristian JB, Bourgeois N, Snipes R, Lowe KA. Prevalence of severe (500 to 2,000 mg/dl) hypertriglyceridemia in United States adults. American Journal of Cardiology. 2011;Mar 15;107(6):891-897.
23. C enters for Disease Control and Prevention. Prevalence of abnormal lipid levels among youths — United States, 1999-2006. Morbidity and Mortality Weekly Report. 2010;Jan 22;59(2):29-33.
24. E arle-Richardson G, Scribani M, Scott E, May J, Jenkins P. A Comparison of Health, Health Behavior, and Access Between Farm and Nonfarm Populations in Rural New York State. The Journal of Rural Health. 2015;31(2):157-164. 25. C enters for Disease Control and Prevention. Vital Statistics, Detailed Tables for the National Vital Statistics Report (NVSR) “Deaths: Final Data for 2013.”. Mortality Multiple Cause Micro-data Files 2013; http://www.cdc.gov/nchs/ data/nvsr/nvsr64/nvsr64_02.pdf.
26. C arroll MD KB, Lacher DA, Shero ST, Mussolino ME. Trends in Lipids and Lipoproteins in US Adults, 1988-2010. Journal of the American Medical Association. 2012;308(15):1545-1554.
27. M ann D, Reynolds K, Smith D, Muntner P. Trends in statin use and low-density lipoprotein cholesterol levels among US adults: impact of the 2001 National Cholesterol Education Program guidelines. Annals of Pharmacotherapy. 2008;Sep;42(9):1208-1215.
28. G u Q, Paulose-Ram R, Burt VL, Kit BK. Prescription Cholesterol-lowering Medication Use in Adults Aged 40 and Over: United States, 2003–2012. NCHS Data Brief 2014; http://www.cdc.gov/nchs/data/databriefs/db177.htm#ref1.
29. O kere AN, Serra C. Evaluation of the Potential Role of Alirocumab in the Management of Hypercholesterolemia in Patients with High-Risk Cardiovascular Disease. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy. 2015;35(8):771-779.
30. Wu BU, Pandol SJ, Liu IL. Simvastatin is associated with reduced risk of acute pancreatitis: findings from a regional integrated healthcare system. Gut. 2015;64(1):133-138.
31. I to MK. Long-chain omega-3 fatty acids, fibrates and niacin as therapeutic options in the treatment of hypertriglyceridemia: A review of the literature. Atherosclerosis. 2015;Oct;242(2):647-656.
32. C apell WH, DeSouza CA, Poirier P, Bell ML, Stauffer BL, Weil KM, Hernandez TL, Eckel RH. Short-term triglyceride lowering with fenofibrate improves vasodilator function in subjects with hypertriglyceridemia. Arteriosclerosis, Thrombosis, and Vascular Biology. 2003;23(2):307-313.
33. Kastelein JJP, Maki KC, Susekov A, Ezhov M, Nordestgaard BG, Machielse BN, Kling D, Davidson MH. Omega-3 free fatty acids for the treatment of severe hypertriglyceridemia: The EpanoVa fOr Lowering Very high triglyceridEs (EVOLVE ) trial. Journal of Clinical Lipidology. 2014;8(1):94-106.
34. D unbar RL, Nicholls SJ, Maki KC, Roth EM, Orloff DG, Curcio D, Johnson J, Kling D, Davidson MH. Effects of omega-3 carboxylic acids on lipoprotein particles and other cardiovascular risk markers in high-risk statin-treated patients with residual hypertriglyceridemia: a randomized, controlled, double-blind trial. Lipids in Health and Disease. 2015;14:98.
35. Zhao A, Lam S. Omega-3-Carboxylic Acid (Epanova) for Hypertriglyceridemia. Cardiology in Review. 2015;23(3).

Back to Top