2021 ACC Expert Consensus Decision Pathway on ASCVD Risk Reduction in Persistent Hypertriglyceridemia

Triglycerides occupy an awkward place in cardiovascular care. They clearly travel with risk, yet for years there was little proof that lowering them did any good — so they were measured, noted, and often ignored. This ACC decision pathway is the attempt to give clinicians something concrete to do about a persistently high triglyceride level once LDL is already controlled.

Its structure is practical, organizing guidance around four groups: patients with established disease, patients with diabetes and added risk, high-risk primary-prevention patients, and those with severe hypertriglyceridemia (where the immediate concern shifts to preventing pancreatitis). The document leans heavily on the REDUCE-IT trial, which showed that icosapent ethyl — a purified prescription omega-3 — reduced cardiovascular events in high-risk patients with elevated triglycerides on a statin. It folds that finding into a stepwise plan, beginning with the foundations the marker most responds to: lifestyle, alcohol, glycemic control, and a review of contributing medications.

The honest qualifiers are several. This is expert consensus, not a guideline; the headline evidence rests substantially on a single trial whose choice of comparator drew scientific debate; and triglyceride-lowering more generally has a checkered trial record. The pathway navigates a genuinely unsettled area.

We rate the evidence moderate. It is a careful, useful synthesis that fills a real gap in the 2018 cholesterol guideline — giving clinicians a defensible route through a risk factor that is easy to measure and, until recently, hard to act on.