Cited by 1,116Lipoproteins and Cardiovascular HealthLipid metabolism and disordersDiabetes, Cardiovascular Risks, and Lipoproteins

Triglyceride-Rich Lipoproteins and Atherosclerotic Cardiovascular Disease: New Insights From Epidemiology, Genetics, and Biology

Nordestgaard, Børge G.·2016·Circulation Research

Abstract

Scientific interest in triglyceride-rich lipoproteins has fluctuated over the past many years, ranging from beliefs that these lipoproteins cause atherosclerotic cardiovascular disease (ASCVD) to being innocent bystanders. Correspondingly, clinical recommendations have fluctuated from a need to reduce levels to no advice on treatment. New insight in epidemiology now suggests that these lipoproteins, marked by high triglycerides, are strong and independent predictors of ASCVD and all-cause mortality, and that their cholesterol content or remnant cholesterol likewise are strong predictors of ASCVD. Of all adults, 27% have triglycerides >2 mmol/L (176 mg/dL), and 21% have remnant cholesterol >1 mmol/L (39 mg/dL). For individuals in the general population with nonfasting triglycerides of 6.6 mmol/L (580 mg/dL) compared with individuals with levels of 0.8 mmol/L (70 mg/dL), the risks were 5.1-fold for myocardial infarction, 3.2-fold for ischemic heart disease, 3.2-fold for ischemic stroke, and 2.2-fold for all-cause mortality. Also, genetic studies using the Mendelian randomization design, an approach that minimizes problems with confounding and reverse causation, now demonstrate that triglyceride-rich lipoproteins are causally associated with ASCVD and all-cause mortality. Finally, genetic evidence also demonstrates that high concentrations of triglyceride-rich lipoproteins are causally associated with low-grade inflammation. This suggests that an important part of inflammation in atherosclerosis and ASCVD is because of triglyceride-rich lipoprotein degradation and uptake into macrophage foam cells in the arterial intima. Taken together, new insights now strongly suggest that elevated triglyceride-rich lipoproteins represent causal risk factors for low-grade inflammation, ASCVD, and all-cause mortality.

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Registry

Crossref · 10.1161/circresaha.115.306249

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  • Triglyceride-rich lipoproteins are thought to be at least as atherogenic as LDL cholesterol on a per-particle basis.

    “triglyceride-rich lipoproteins are thought to be at least as atherogenic as LDL cholesterol on a perparticle basis. 19,21”

    From Targeting <i>APOC3</i> with Olezarsen in Moderate Hypertriglyceridemia (2025) · cites this paper as [21]

    The Biology section says medium-sized triglyceride-rich lipoproteins can enter the arterial intima and may be trapped there preferentially to LDL, supporting their atherogenic potential. It does not establish that they are at least as atherogenic as LDL on a per-particle basis; the same section notes that very large chylomicrons cannot enter the intima. (LLM, conf=0.84)

    Experimental — accuracy not yet measured
  • TG reduction lowers several inflammatory markers associated with CV risk.

    “Furthermore, TG reduction lowers several inflammatory markers associated with CV risk, and subgroup and post hoc analyses of outcome studies suggest possible reductions in major CV events with TG‐lowering therapy.3, 4, 5, 6, 7, 8, 9, 10, 11”

    From Rationale and design of <scp>REDUCE‐IT</scp> : Reduction of Cardiovascular Events with Icosapent Ethyl–Intervention Trial (2017) · cites this paper as [3]

    The Biology section reports a causal association between higher triglyceride-rich lipoproteins and low-grade inflammation, measured by C-reactive protein. It does not report reductions in several inflammatory markers following TG-lowering therapy; the Conclusion and Perspectives section says intervention-trial evidence for reduced inflammation is still needed. No page number is available in our copy. (LLM, conf=0.86)

    Experimental — accuracy not yet measured
  • Elevated levels of triglyceride-rich lipoproteins and remnant lipoproteins contribute directly to atherosclerosis by promoting endothelial dysfunction, inflammation, and foam cell formation.

    “Elevated levels of TRLs and remnant lipoproteins contribute directly to atherosclerosis by promoting endothelial dysfunction, inflammation, and foam cell formation [8, 9].”

    From Targeting Triglycerides in Cardiovascular Disease Prevention: Evidence, Mechanisms, and Emerging Therapies (2026) · cites this paper as [8]

    The Biology section describes triglyceride-rich lipoproteins entering the arterial intima, likely generating local inflammation, and being taken up by macrophages to form foam cells. It cautions that evidence for the proposed intimal inflammation mechanism in humans is not strong. Our copy does not establish endothelial dysfunction as a mechanism; crossing the endothelial barrier is not the same claim. (LLM, conf=0.87)

    Experimental — accuracy not yet measured
  • Cholesterol-enriched remnant particles may enter the arterial intima and contribute to atherosclerosis, whereas nascent chylomicrons and very large VLDL particles do not cross the endothelial layer.

    “These cholesterol-enriched remnant particles may enter the arterial intima and contribute to atherosclerosis, whereas nascent chylomicrons and very large VLDL particles do not cross the endothelial layer [17].”

    From Quantifying atherogenic lipoproteins for lipid-lowering strategies: Consensus-based recommendations from EAS and EFLM (2020) · cites this paper as [17]

    The Biology section (page unavailable) says medium-sized triglyceride-rich lipoproteins can enter the arterial intima and become trapped, while large chylomicrons are too large to cross the endothelial barrier. It does not establish the same exclusion for very large VLDL particles, so that part of the claim is unsupported. (LLM, conf=0.86)

    Experimental — accuracy not yet measured
  • TRL remnants range in diameter from approximately 30 to 80 nm, enabling passage across the endothelial barrier, unlike large chylomicrons whose size often exceeds 1000 nm.

    “Unlike large chylomicrons, whose size often exceeds 1000 nm and restricts transendothelial passage, triglyceride-rich lipoprotein remnants, including chylomicron remnants, VLDL remnants, and IDL, range in diameter from approximately 30 to 80 nm, enabling passage across the endothelial barrier [16].”

    From Targeting triglycerides for cardiovascular risk reduction (2026) · cites this paper as [16]

    The Biology section (page unavailable) says large chylomicrons are too large to cross the endothelial barrier, while medium-sized triglyceride-rich lipoproteins can enter the arterial intima. The copy identifies VLDL, IDL, and chylomicron remnants as relevant lipoproteins, but does not give the claimed 30–80 nm remnant range or say chylomicrons often exceed 1000 nm. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

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Research works printed but not linked: 2

  1. [7]7. Wood D, De Backer G, Faergeman O, Graham I, Mancia G, Pyörälä K. Prevention of coronary heart disease in clinical practice: recommenda- tions of the Second Joint Task Force of European and other Societies on Coronary Prevention. Atherosclerosis. 1998;140:199-270.
  2. [19]19. Goldstein JL, Hobbs HH, Brown MS. Familial hypercholesterolemia. In: Scriver CR, Beaudet AL, Sly WS, Valle D, eds. The Metabolic & Molecular Bases of Inherited Disease. 8th ed. New York: McGraw-Hill; 2001:2863-2913.

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Authors
Nordestgaard, B. G.
Affiliations
University of Copenhagen (DK)
Corresponding author
Nordestgaard, Børge G.
Venue
Circulation Research
Published
2016-02-19
Volume
118
Issue
4
Pages
547-563
ISSN
  • 0009-7330 (ISSN-L)
  • 1524-4571
OpenAlex
W2286999219
Cited by
1,116
References
131
Citations by year
2026: 121 · 2025: 146 · 2024: 140 · 2023: 138 · 2022: 123 · 2021: 116 · 2020: 106 · 2019: 82 · 2018: 61 · 2017: 64 · 2016: 18
FWCI
83.03
Type
journal article
Language
en
Open access
closed
Locations
  • Circulation Research (publishedVersion)
  • PubMed (publishedVersion)
  • Research at the University of Copenhagen (University of Copenhagen) (publishedVersion)
Topics
  • Health Sciences › Medicine › Surgery › Lipoproteins and Cardiovascular Health
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Lipid metabolism and disorders
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
Keywords
triglyceride-rich lipoproteins, atherosclerotic cardiovascular disease, remnant cholesterol, hypertriglyceridemia, all-cause mortality, cardiovascular risk prediction, Mendelian randomization, low-grade inflammation, foam cells, atherosclerosis, ischemic heart disease, ischemic stroke, myocardial infarction
MeSH terms
Animals, Hypolipidemic Agents, Humans, Lipoproteins, Cholesterol, HDL, Cholesterol, LDL, Phenotype, Primary Prevention, Prognosis, Risk Factors, Triglycerides, Hypertriglyceridemia, Biomarkers, Risk Assessment, Genetic Predisposition to Disease, Atherosclerosis

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