Dr. Ginsberg's recommendations for treatment of hypertriglyceridemia [1] are not supported by currently available evidence. First, Dr. Ginsberg offers potential biochemical rationales for how hypertriglyceridemia could cause atherosclerosis. Such explanations might be true but are an insufficient basis for establishing clinical policy. Second, he correctly notes that the observational data are inconsistent; indeed, most data do not support an independent role for hypertriglyceridemia in this process [2]. Third, he cites the Helsinki Heart Study as the primary clinical trial evidence for lowering triglyceride levels to reduce risk for coronary heart disease. However, analyses from this study showed that the risk reduction provided by gemfibrozil treatment was attributed to changes in levels of cholesterol subfractions only, not triglyceride levels; this was also true of patients with type IV hyperlipidemia [3]. Similar analyses were done in the Coronary Drug Project; the Lipid Research Clinics Coronary Primary Prevention Trial; and the National Heart, Lung, and Blood Type II studies; in each of these trials, no significant associations were seen between changes in triglyceride levels and changes in risk for coronary heart disease [2]. Dr. Ginsberg also mentions the triglyceride-cholesterol interaction found in the Helsinki study; this post hoc finding is not consistent with some other analyses of triglyceride-cholesterol interactions and requires greater confirmation before it can be advocated for general clinical use [4].

Finally, Dr. Ginsberg recommends niacin, statins, or gemfibrozil for treatment of hypertriglyceridemia if diet fails. Given the serious paucity of data supporting a benefit of lowering triglyceride levels, it seems particularly ill-advised to prescribe drugs that are associated with serious side effects, great expense, or elevated risk for conditions other than coronary heart disease [5]. Until better evidence becomes available, physicians would be better advised to put their energies into recommending the many well-proven preventive measures for reducing risk for coronary heart disease and avoiding treatment directed specifically at triglyceride levels.