Case Report: Severe hypertriglyceridaemia and multivessel coronary artery disease – management and plaque characteristics

Background: Elevated triglycerides have been established as a cardiovascular risk marker and the literature suggests an association with lipid-rich plaques. We report a case of severe hypertriglyceridaemia that did not result in lipid-rich atherosclerotic lesions. Case summary: Coronary angiography of a 54-year-old man with a triglyceride level >113.00 mmol/L revealed severe multivessel disease. Near-infrared spectroscopy (NIRS) demonstrated a low plaque lipid content, including the maximum lipid-core burden index within 4 mm of 0 in the right coronary artery (RCA), with >90% stenosis in the middle segment. To achieve a rapid reduction in the triglyceride level, intravenous administration of insulin and heparin combined with subsequent plasmapheresis was used, and a triglyceride level of 5.79 mmol/L was achieved before discharge. Genetic testing confirmed familial hypertriglyceridaemia with a pathogenic variant in the lipoprotein lipase gene. Conclusions: In a patient with severely elevated serum triglycerides and premature three-artery disease, low plaque lipid content was established with the NIRS investigation. Pharmacological management of very severe hypertriglyceridaemia with intravenous insulin and heparin therapy can rapidly decrease triglyceride levels.