Triglyceride-Rich Lipoproteins and Atherosclerotic Cardiovascular Disease: New Insights From Epidemiology, Genetics, and Biology
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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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 measuredTG 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 measuredElevated 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 measuredCholesterol-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 measuredTRL 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
Atherogenicity of TRLs largely depends on the structural and functional properties of their remnant particles, which are smaller and enriched in cholesterol relative to parental TRLs.
“Atherogenicity of TRLs largely depends on the structural and functional properties of their remnant particles, which are smaller and enriched in cholesterol relative to their parental TRLs.”
From Targeting triglycerides for cardiovascular risk reduction (2026) · cites this paper as [16]
The Biology section links atherogenicity to particle size: very large chylomicrons cannot enter the arterial intima, whereas medium-sized triglyceride-rich lipoproteins can. The Copenhagen General Population Study section describes remnant cholesterol as a causal ASCVD risk factor. Our copy does not explicitly say that remnants are cholesterol-enriched relative to their parent particles or that TRL atherogenicity largely depends on those remnants’ structural and functional properties. (LLM, conf=0.83)
Experimental — accuracy not yet measuredIn familial chylomicronemia syndrome, standard lipid-lowering therapies such as fibrates and omega-3 fatty acids are largely ineffective, and statins often fail to achieve adequate triglyceride reduction.
“The absence of LPL activity renders standard lipid-lowering therapies—such as fibrates and omega-3 fatty acids—largely ineffective. Similarly, statins often fail to achieve adequate TG reduction in these patients.”
From The Efficacy and Safety of Plozasiran on Lipid Profile in Dyslipidemic Disorders: A Systematic Review and Meta-Analysis (2026) · cites this paper as [7]
The Biology section (page not provided) says chylomicronemia caused by lipoprotein lipase deficiency involves no triglyceride degradation in plasma, supporting the sentence’s premise. It does not say that fibrates or omega-3 fatty acids are ineffective in these patients, or that statins fail to reduce their triglycerides adequately. The Randomized Trials section discusses these drugs in other populations, not their efficacy in familial chylomicronemia. (LLM, conf=0.83)
Experimental — accuracy not yet measuredAll forms of dyslipidemia significantly increase the risk of atherosclerotic cardiovascular disease and all-cause mortality, primarily due to elevated LDL-C, triglycerides, triglyceride-rich lipoproteins, and their remnants.
“All forms of dyslipidemia significantly increase the risk of atherosclerotic cardiovascular disease (ASCVD) and all-cause mortality, primarily due to elevated LDL-C levels, triglycerides (TGs), triglyceride-rich lipoproteins (TRLs), and their remnants [7].”
From The Efficacy and Safety of Plozasiran on Lipid Profile in Dyslipidemic Disorders: A Systematic Review and Meta-Analysis (2026) · cites this paper as [7]
The Abstract reports that triglyceride-rich lipoproteins predict ASCVD and all-cause mortality, and that remnant cholesterol predicts ASCVD. But the paper does not support the claim about *all* forms of dyslipidemia: its Abstract says low HDL cholesterol is unlikely to cause ASCVD, and its Biology section describes severe hypertriglyceridemia without increased atherosclerosis. It also distinguishes LDL-related cholesterol from triglycerides in its discussion of all-cause mortality. (LLM, conf=0.88)
Experimental — accuracy not yet measuredTriglyceride elevation is an independent risk factor for cardiovascular events.
“Clinical and epidemiological studies have demonstrated that triglyceride (TG) elevation is an independent risk factor for increased cardiovascular (CV) events”
From Rationale and design of <scp>REDUCE‐IT</scp> : Reduction of Cardiovascular Events with Icosapent Ethyl–Intervention Trial (2017) · cites this paper as [3]
Residual cardiovascular risk persists despite statin therapy.
“despite potent therapies for lowering low‐density lipoprotein cholesterol (LDL‐C), substantial residual risk remains.1, 2, 3”
From Rationale and design of <scp>REDUCE‐IT</scp> : Reduction of Cardiovascular Events with Icosapent Ethyl–Intervention Trial (2017) · cites this paper as [3]
Mendelian randomization studies support a causal role for triglycerides in the pathogenesis of cardiovascular disease.
“More recently, elegant Mendelian randomization studies have supported a causal role for TG in the pathogenesis of cardiovascular disease (CVD), showing that elevated TG are not merely a risk marker, but rather a risk factor and thus potentially modifiable.3”
From Rationale and design of <scp>REDUCE‐IT</scp> : Reduction of Cardiovascular Events with Icosapent Ethyl–Intervention Trial (2017) · cites this paper as [3]
Subgroup and post hoc analyses of outcome studies suggest possible reductions in major CV events with TG-lowering therapy.
“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]
Epidemiological, biological, and genetic studies have provided robust evidence of a strong association between elevated TG levels and higher rates of CV events.
“Epidemiological, biological, and genetic studies have provided robust evidence of a strong association between elevated TG levels and higher rates of CV events.1, 2, 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]
Randomized data from large outcome studies across broad populations regarding pharmacological TG lowering and effect on CV outcomes have been mixed.
“However, randomized data from large outcome studies across broad populations regarding pharmacological TG lowering and effect on CV outcomes have been mixed (Table 4).1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24”
From Rationale and design of <scp>REDUCE‐IT</scp> : Reduction of Cardiovascular Events with Icosapent Ethyl–Intervention Trial (2017) · cites this paper as [3]
Remnant lipoproteins are causal contributors to atherogenesis.
“Genetic studies and epidemiologic data increasingly implicate remnant lipoproteins as causal contributors to atherogenesis, providing a strong mechanistic and clinical rationale for targeted intervention [8–12].”
From Targeting Triglycerides in Cardiovascular Disease Prevention: Evidence, Mechanisms, and Emerging Therapies (2026) · cites this paper as [8]
Mendelian randomization studies suggest that life-long high serum concentrations of TG-rich lipoproteins or their remnants are causally associated with increased risk of ASCVD and all-cause mortality.
“Mendelian randomization studies suggest that life-long high serum concentrations of TG-rich lipoproteins or their remnants are causally associated with increased risk of ASCVD and all-cause mortality [17,18].”
From Quantifying atherogenic lipoproteins for lipid-lowering strategies: Consensus-based recommendations from EAS and EFLM (2020) · cites this paper as [17]
Hypertriglyceridemic samples with TG >2 mmol/L are seen in ~25% of individuals in the general population.
“hypertriglyceridemic samples -TG > 2 mmol/L seen in ~25% of individuals in the general population (Tables 23) [17]”
From Quantifying atherogenic lipoproteins for lipid-lowering strategies: Consensus-based recommendations from EAS and EFLM (2020) · cites this paper as [17]
Non-HDLC provides a more comprehensive risk assessment than LDLC in certain individuals with hypertriglyceridemia because it adds RemnantC to LDLC and, therefore, takes into account the atherogenic potential of remnant lipoproteins.
“Non-HDLC provides a more comprehensive risk assessment than LDLC in certain individuals with hypertriglyceridemia because it adds Re-mnantC to LDLC and, therefore, takes into account the atherogenic potential of remnant lipoproteins [17].”
From Quantifying atherogenic lipoproteins for lipid-lowering strategies: Consensus-based recommendations from EAS and EFLM (2020) · cites this paper as [17]
A TG concentration above 10 mmol/L in nonfasting blood samples is only seen in ~0.1% of individuals in the general population.
“Far higher than the maximum allowed TG concentration of 4.5 mmol/L for cLDLC, most nephelometric and turbidimetric apoB measurements are limited to TG < 10 mmol/L due to interference of light scattering or absorption caused by chylomicrons and large VLDLs; a TG concentration above this limit in nonfasting blood samples is only seen in ~0.1% of individuals in the general population [17].”
From Quantifying atherogenic lipoproteins for lipid-lowering strategies: Consensus-based recommendations from EAS and EFLM (2020) · cites this paper as [17]
Triglyceride-rich lipoproteins are atherogenic and causally associated with cardiovascular disease.
“As triglyceride-rich lipoproteins are atherogenic and causally associated with cardiovascular disease,44,45”
The findings of high apoE levels and high cardiovascular mortality may be mediated by triglyceride-rich lipoproteins via remnant cholesterol content.
“our findings of high apoE levels and high cardiovascular mortality may be mediated by triglyceride-rich lipoproteins via remnant cholesterol content”
A concentration of nonfasting TG ≥4.5 mmol/L is seen in ~3-5% of nonfasting individuals in the general population.
“Fasting is an option when nonfasting TG are ≥4.5 mmol/L, a concentration seen in ~3-5% of nonfasting individuals in the general population (Tables 23) [17]”
From Quantifying atherogenic lipoproteins for lipid-lowering strategies: Consensus-based recommendations from EAS and EFLM (2020) · cites this paper as [17]
The Measurement and Population Distribution section reports that 27% of adults in the Copenhagen population have triglycerides of 2–10 mmol/L, but gives no prevalence for nonfasting triglycerides ≥4.5 mmol/L. Figure 2 shows a distribution, yet the text available in our copy does not establish the claimed ~3–5% figure. I searched for the 4.5 mmol/L threshold and its associated percentage. (LLM, conf=0.72)
Experimental — accuracy not yet measuredCurrently available therapies are not effective enough to reach guideline-recommended therapeutic goals in acquired severe hypertriglyceridemia.
“Moreover, currently available therapies haven’t been effective enough to reach guideline-recommended therapeutic goals in acquired severe hypertriglyceridemia [5, 7, 8].”
From The Efficacy and Safety of Plozasiran on Lipid Profile in Dyslipidemic Disorders: A Systematic Review and Meta-Analysis (2026) · cites this paper as [7]
The Abstract (page unavailable) says guidelines recommend lowering severely elevated triglycerides to reduce pancreatitis risk. It does not say whether available therapies achieve those goals, and searches for acquired severe hypertriglyceridemia and treatment targets found no passage addressing their effectiveness. (LLM, conf=0.74)
Experimental — accuracy not yet measuredRecent advances in human genetics, epidemiologic, preclinical, and clinical trial results provide strong support for a causal association between triglycerides, triglyceride-rich lipoproteins, and triglyceride-rich lipoprotein remnants and increased risk of myocardial infarction, ischaemic stroke, and aortic valve stenosis.
“Recent advances in human genetics, together with a large body of epidemiologic, preclinical, and clinical trial results, provide strong support for a causal association between triglycerides (TG), TG-rich lipoproteins (TRL), and TRL remnants, and increased risk of myocardial infarction, ischaemic stroke, and aortic valve stenosis.”
Over the past three decades, epidemiologic and genetic evidence supports that elevated plasma levels of triglycerides, triglyceride-rich lipoproteins, and triglyceride-rich lipoprotein remnants are causally related to increased risk of atherosclerotic cardiovascular disease-related events, including myocardial infarction, stroke, and aortic valve stenosis, and all-cause mortality.
“Over the past three decades, epidemiologic and genetic evidence has accumulated to support the concept that elevated levels of plasma TG, TRL, and TRL remnants are causally related to an increased risk of ASCVD-related events—myocardial infarction (MI), stroke, and aortic valve stenosis—and all-cause mortality.1,2,17,19,20,24–28”
The increase in absolute risk is greatest for myocardial infarction, approximately four-fold at triglyceride levels above 5 mmol/L versus below 1 mmol/L, and less for ischaemic stroke and aortic stenosis.
“The increase in absolute risk is greatest for MI (approximately four-fold at TG levels >5 mmol/L or >440 mg/dL vs. <1 mmol/L or <88 mg/dL), and less for ischaemic stroke and aortic stenosis (Figure 3).11,17,27,28”
Hepatic clearance of VLDL remnants is mediated by either apoB100 or apoE through receptor-dependent and receptor-independent pathways; 25-75% of these particles are removed directly rather than converted to LDL.
“Hepatic clearance of VLDL remnants is mediated by either apoB100 or apoE through receptor-dependent and receptor-independent pathways;7,17,71,73 25–75% of these particles are removed directly rather than converted to LDL.”
Plasma triglyceride levels range from 0.33 to 120 mmol/L, reflecting variability in the rates of secretion and clearance of triglyceride and apoB in VLDL and chylomicrons.
“Plasma TG levels range from 0.33 to 120 mmol/L (30 to 10 000 mg/dL)13,17 (Figure 6), reflecting variability in the rates of secretion and clearance of TG and apoB in VLDL and chylomicrons.61,77”
The proteomes of TRL and remnant particles contain a single copy of either apoB48 or apoB100, together with other smaller apolipoproteins (CIII, CII, CI, AIV, AV, E, and traces of AI and II) and ANGPTL-3, -4, and -8.
“The proteomes of TRL and remnant particles contain a single copy of either apoB48 or apoB100, together with other, smaller apolipoproteins (CIII, CII, CI, AIV, AV, E, and traces of AI and II) and ANGPTL-3, -4, and -8.”
There is no evidence that TG directly exert atherogenic effects.
“While there is no evidence that TG directly exert atherogenic effects,17”
Any proatherogenic effects of TRL and remnants will be synergistic to those of other apoB-containing lipoproteins, particularly LDL and lipoprotein(a).
“any proatherogenic effects of TRL and remnants will be synergistic to those of other apoB-containing lipoproteins, particularly LDL and lipoprotein(a).17,25,93,104,206”
ApoE-mediated macrophage uptake of VLDL and remnants promotes an inflammatory (M1) phenotype, enhances inflammation, increases phagocytosis and foam cell formation, exerts defective efferocytotic activity, and favours fibrous cap thinning due to activation of metalloprotease expression.
“ApoE-mediated macrophage uptake of VLDL and remnants promotes an inflammatory (M1) phenotype,2,17,139 enhances inflammation, increases phagocytosis and foam cell formation, exerts defective efferocytotic activity, and favours fibrous cap thinning due to activation of metalloprotease expression140”
Particles below ∼70 nm diameter (excluding most newly secreted, non-lipolysed chylomicrons and very large VLDL) traverse the endothelium by active transcytosis and are retained in the subendothelial layer of the artery wall, contributing to lesion initiation and progression mainly by cholesterol deposition, inflammation, and prothrombotic effects.
“Particles below ∼70 nm diameter (which excludes most newly secreted, non-lipolysed chylomicrons and very large VLDL) traverse the endothelium by active transcytosis93 and are retained in the subendothelial layer of the artery wall, contributing to lesion initiation and progression mainly by mechanisms involving cholesterol deposition, inflammation, and prothrombotic effects”
Assays that specifically measure the cholesterol content of remnant particles have revealed significant associations with ASCVD.
“Assays that specifically measure the cholesterol content of remnant particles have revealed significant associations with ASCVD.17,86”
In patients with stable angina who were receiving lipid-lowering treatment, the risk for cardiovascular events after treatment using a drug-eluting stent increases by 1.14 times with every 10 U/L elevation in MDA-LDL levels.
“In patients with stable angina who were receiving lipid-lowering treatment, the risk for cardiovascular events after treatment using a drug-eluting stent has been shown to increase by 1.14 times with every 10 U/L elevation in MDALDL levels237).”
From Japan Atherosclerosis Society (JAS) guidelines for prevention of atherosclerotic cardiovascular diseases 2017 (2018) · cites this paper as [237]
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Maiorca, C., Tramontano, D., Di Costanzo, A., & D’Erasmo, L. (2026) · Internal and Emergency Medicine · doi:10.1007/s11739-026-04383-1
- 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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