Triglycerides 200 to 499 mg/dL

A fasting triglyceride of 200 to 499 mg/dL is high in ATP III's 2001 classification, "High triglycerides: 200-499 mg/dL", and 200 is where the panel widened the target. Its new-features table says it "Recommends treatment beyond LDL lowering for persons with triglycerides ≥200 mg/dL." The added target was non-HDL cholesterol, total cholesterol minus HDL, with a 2001 goal set 30 mg/dL above the LDL goal "on the premise that a VLDL cholesterol level ≤30 mg/dL is normal."

What 2026 kept, and what it dropped. The March 2026 ACC/AHA guideline has no separate high band. Its 150 to 499 tier starts with secondary causes and lifestyle, covered on the borderline high page. The measurement survived: Recommendation 7 of Section 4.2.9 (Class 2a) prefers non-HDL cholesterol or apoB (apolipoprotein B) over LDL cholesterol for guiding decisions once triglycerides reach 150. ATP III's option to add "nicotinic acid or fibrate" did not: "Neither fibrates nor niacin are recommended for routine use due to lack of proven reductions in ASCVD events when added to statin therapy."

Who gets a statin. Statins remain the first-line drug for lowering ASCVD (atherosclerotic cardiovascular disease) risk at any triglyceride level under 1000. For adults 40 to 75 without ASCVD or diabetes whose elevation persists, Recommendation 5 (Class 1) is to estimate 10-year risk with the PREVENT-ASCVD equations and let it guide the lifestyle and statin discussion. By risk level: low, diet and lifestyle with periodic reassessment; borderline to intermediate, a statin plus lifestyle as first-line therapy; high, lifestyle plus moderate- to high-intensity statin therapy. Two figures for the TG drop: "on average by 20% to 40%" (Section 4.2.9) and "10% to 30% in a dose-dependent manner" (Section 4.2.1.3).

One add-on, with conditions. Icosapent ethyl is the only triglyceride-lowering medication the guideline credits with lowering ASCVD event risk alongside a statin. Recommendation 4 (Class 2b) says adding it "may be reasonable" for adults 50 or older with ASCVD, or with diabetes plus at least one risk factor, with LDL under 100 on the highest statin dose they tolerate. On icosapent ethyl, hospitalization for new-onset atrial fibrillation (at low overall rates) and serious bleeding were both more common than on placebo.

Test rules that start in this band. Section 3.2 calls for a fasting repeat at a nonfasting 400 or higher (Class 1), "to more accurately estimate the LDL-C level", and says one "may also be considered" from a nonfasting 200 when hypertriglyceridemia needs further evaluation. A related limit on estimating LDL: "The Friedewald equation cannot be used if the TG level is ≥400 mg/dL (≥4.5 mmol/L)." Table 9 lists lipid-specialist referral at 400 or higher for anyone considering pregnancy, pregnant or breastfeeding. The guideline's pancreatitis warnings start at 500.