高脂血癥的一級預(yù)防和二級預(yù)防課件

1、 68% 18% 14% 0 20 40 60 80 % Stenosis Percent of MI Patients PCI CABG -30 -33 -29-28 -22 -40 -30 -20 -10 0 LDL-CStroke Total mortality % * * *Confidence interval (CI) not reported. 95% CI, 14%-41%. 95% CI, 16%-37%. 95% CI, 12%-31%. Hebert PR et al. JAMA. 1997;278:313-321. Nonfatal/ fatal CHD CVD mor

2、tality Pyrl K et al. Diabetes Care. 1997;20:614-620. 0.50 0.60 0.70 0.80 0.90 1.00 0.00 1.00 2.00 3.00 4.00 5.00 0123456 Proportion without major CHD event Yr since randomization - P=0.002 - P=0.0001 Diabetic, simvastatin Diabetic, placebo Nondiabetic, simvastatin Nondiabetic, placebo 32% 55% Haffne

3、r SM et al. Diabetes. 1998;(suppl 1):A54. Abstract. -46 -56 -40 -43 -60 -50 -40 -30 -20 -10 0 Total mortality Coronary mortality Major coronary events Revas- culari- zations in events (%) P=0.005 P=0.001 P=0.010 MIRACL Acute coronary event 4S3 AFCAPS / TexCAPS/ WOSCOPS CARE1 LIPID2 No history of CAD

4、 Acute Coronary Syndromes 3 mo t=0 6 mo Randomization: CARE - 320 mo LIPID - 336 mo Randomization: 6 mo Stable CAD Duration of follow-up: 15.0 years; 26.1 years; 35.4 years. Schwartz GG et al. Am J Cardiol 1998;81:578581. 7 12 4 9 -27 5 -16 -50 -40 -30 -20 -10 0 10 20 TCHDL-CTG Placebo Atorvastatin

5、80 mg % Data from Schwartz GG et al. JAMA. 2001;285:1711-1718. Additional data courtesy of GG Schwartz. unstable angina or nonQ-wave MI 3,086randomized 2496 h after admission Followed 16 weeks 0 5 10 15 0481216 Time since randomization (wk) Cumulative incidence (%) RR = 0.84 (95% CI, 0.70-1.00) P =

6、0.048 Atorvastatin Placebo 17.4 14.8 *Death (any cause), nonfatal MI, resuscitated cardiac arrest, recurrent symptomatic myocardial ischemia with objective evidence requiring emergency rehospitalization. Schwartz GG et al. JAMA. 2001;285:1711-1718. 0.250.500.751.001.252.00 better Relative risk Death

7、 Nonfatal MI Resuscitated cardiac arrest No. (%) of events * Adapted from Schwartz GG et al. JAMA. 2001;285:1711-1718. 0.0 0.5 1.0 1.5 2.0 0481216 Time since randomization (wk) RR = 0.50 (95% CI, 0.26-0.99) P = 0.045 Placebo 1.6 Cumulative incidence (%) Data from Schwartz GG et al. JAMA. 2001;285:17

8、11-1718. 19,599 men and women 80 yo discharged post AMI, 58 Swedish Hospitals, 1995-1998 5528 (28%) statin rx vs 14071 (72%) no statin rx, highest hospital rates of use 48%; lowest 12% Stenestrand JAMA 2001;285;430-436 RR 0.75 (0.63-0.89) P=0.001 25% Risk Reduction Heeschen C et al. Circulation. 200

9、2;105:1446-1452. 051015202530 18 16 14 12 10 8 6 4 2 0 Follow-up (day) Event rates (%) Statins discontinued No statins Statins continued Grundy. Circulation. 1998;97:1436-1439. The quantitative relation between the magnitude of cholesterol lowering and CHD reduction has not been precisely defined 3

10、models a) Linearb) Thresholdc) Curvilinear 25 20 15 10 5 0 507090110130150170190210 TNT 80mg TNT 10 mg CARE-S LIPID-S 4S-S CARE-P LIPID-P TNT Entry 4S-P CHD Event (%) LDL-C (mg/dL) Correlation Between CHD Events and LDL-C Levels S=Statin treated; P=Placebo treated AVERT 80mg: LDL=77 mg/dL 13.4% Even

11、t Rate IIIa IIbIII = ACC/AHA Practice Guidelines ACC AHA SIMVASTATIN: VASCULAR EVENT by AGE 360:7-22. ARR=absolute risk reduction; NNT=number needed to treat. 2002 Thomson Professional Postgraduate Services HPS Collaborative Group. Lancet. 2002;360:7-22. HPS enrolled high-risk pr

12、imary- and secondary-prevention patients. HPS. Lancet. 2002;360:7. Downs. JAMA. 1998;279:1615. LIPID. N Engl J Med. 1998;339:1349. Sacks. N Engl J Med. 1996;335:1001. 4S. Lancet. 1995;345:1274. Shepherd. N Engl J Med. 1995;333:1301. % with CHD event Mean LDL-C level at follow-up (mg/dL) 0 5 10 15 20

13、 25 30 90110130150170190210 CARE-Rx LIPID-Rx 4S-Rx CARE-PI LIPID-PI 4S-PI 2 Prevention 1 Prevention WOSCOPS-PI WOSCOPS-Rx AFCAPS-Rx AFCAPS-PI HPS-Pl HPS-Rx HPS-Rx HPS-Pl w/revasc+ stroke CHD only PI=placebo Rx=treatment 70 2002 Thomson Professional Postgraduate Services Downs JR,

14、 et al. JAMA. 1998;279:1615. 0 1 2 3 4 5 6 7 8 Lovastatin Placebo 34 403539 HDL-C Tertile (mg/dL) Events, % *P0.01; P=0.006; P=0.05 P=placebo group; Rx=treated group. Presented by HB Rubins at the 71st annual AHA Scientific Sessions; Dallas, Texas. Subjects: 2,531 men Age: 74 (avg 64) yr Mean baseli

15、ne LDL-C: 111 mg/dL Mean baseline HDL-C: 32 mg/dL Mean baseline TG: 161 mg/dL Duration: 7 yr Intervention: Gemfibrozil 600 mg bid 4 7.5 -24.5 -22 -21 -27 -10 -30 -25 -20 -15 -10 -5 0 5 10 %+ * * LDL-CHDL-C TG Nonfatal MI/CHD death CHD death All-cause mortality Stroke Brown BG, et al. N Engl J Med. 2001;345:1583 23.7 2.6 21.4 14.3 0 5 10 15 20 25 89% Reduction * *P .05 vs placebo Placebo S + N AV S + N + AV Pearson TA, et al. Arch Intern Med. 2000;160:459. 0 40 80 Percent of Pa