成人動脈粥樣硬化風(fēng)險之血膽固醇治療指南內(nèi)容簡介ppt課件

1、2021 ACC/AHA成人膽固醇治療指南內(nèi)容簡介鄭州大學(xué)第二附屬醫(yī)院心內(nèi)科 董靜.爭議美國周刊：2021年十大醫(yī)療突破第2位胡大一：趙程度：“新指南在未獲得明確否認(rèn)證據(jù)前，取消降脂目的值似乎過于武斷。Guidelines are not a replacement for clinical judgment; they are meant to guide and inform decision-making. .新指南的產(chǎn)生.關(guān)鍵性問題Critical questions ( CQs )CQ1: What is the evidence for LDLC and non-HDLC goal

2、s for the secondary prevention of ASCVD?CQ2: What is the evidence for LDLC and non-HDLC goals for the primary prevention of ASCVD?CQ3: Efficacy and Safety of Cholesterol-Lowering Medications*ASCVD ( atherosclerotic cardiovascular disease ): coronary heart disease , stroke, and peripheral arterial di

3、sease.證據(jù)復(fù)習(xí)證據(jù)選擇The highest quality evidence (1995 to 2021)Randomized controlled trials (RCTs) systematic reviewsmeta-analyses of RCTs with hard ASCVD outcomes of MI, stroke and cardiovascular deathwho should get which therapy at what intensityObservational studies and those with 18 months (CQs 1 and

4、2) or 12 months (CQ3) of follow-up were excluded.證據(jù)復(fù)習(xí)證據(jù)結(jié)果不論一級預(yù)防或二級預(yù)防，他汀治療均能明確地減少ASCVD事件的發(fā)生心衰或長期血透患者例外。沒有找到支持降脂藥物滴定治療以到達(dá)特定LDL-C或非HDL-C目的值的循證證據(jù)。在LDL-C或非HDL-C到達(dá)目的值后，運(yùn)用非他汀藥物如煙酸進(jìn)一步降低非HDL-C值，并沒有進(jìn)一步降低ASCVD事件。對四類非常能夠獲益的人群應(yīng)該運(yùn)用適宜強(qiáng)度的他汀治療以降低ASCVD風(fēng)險。.主要內(nèi)容Focus on ASCVD Risk Reduction: 4 statin benefit groupsA Ne

5、w Perspective on LDLC and/or Non-HDLC GoalsGlobal Risk Assessment for Primary PreventionSafetyRole of Biomarkers and Noninvasive TestsFuture Updates to the Blood Cholesterol Guideline.四類他汀獲益人群人群確定運(yùn)用他汀進(jìn)展二級預(yù)防和高?；颊叩囊患夘A(yù)防，ASCVD降低的獲益大于不良反響的風(fēng)險，凈獲益，無論基線LDL-C程度如何。臨床存在ASCVD者原發(fā)性LDL-C190mg/dl40-75歲，糖尿病，臨床無ASCVD

6、，LDL-C 70-189mg/dl40-75歲，無糖尿病，臨床無ASCVD，LDL-C 70-189mg/dl ，估計(jì)10年ASCVD風(fēng)險7.5%者*雖然NYHA分級較高的心衰患者和血透患者心血管風(fēng)險也較高，但不太能夠從他汀治療中獲益。.四類他汀獲益人群他汀強(qiáng)度.主要內(nèi)容Focus on ASCVD Risk Reduction: 4 statin benefit groupsA New Perspective on LDLC and/or Non-HDLC GoalsGlobal Risk Assessment for Primary PreventionSafetyRole of Bio

7、markers and Noninvasive TestsFuture Updates to the Blood Cholesterol Guideline.LDL-C目的值新觀念沒有找到支持降脂藥物滴定治療以到達(dá)LDL-C或非HDL-C目的值的循證證據(jù)HPS：辛伐他汀 40 mg vs. 撫慰劑; 無LDL-C目的ASCOT：阿托伐他汀 10 mg vs. 撫慰劑; 無LDL-C目的PROVE-IT：阿托伐他汀 80 mg vs. 普伐他汀 40 mgTNT：阿托伐他汀 80 mg vs. 阿托伐他汀 10 mgAFCAPS：遞增洛伐他汀劑量至LDL-C目的為110 mg/dl4S：調(diào)整辛伐

8、他汀劑量使TC200 mg/dlPost-CABG：目的值 60-85 mg/dl (實(shí)踐值 95 mg/dl) vs. 130-140 mg/dl (實(shí)踐值 134 mg/dl)，研討結(jié)果為陰性.LDL-C目的值新觀念為什么之前會存在目的LDL-C？許多研討的治療組確實(shí)到達(dá)了LDL-C 100 mg/dl或70 mg/dl 左右的程度, 并且ASCVD事件進(jìn)一步降低，因此我們覺得合理置信流行病研討中顯示的LDL-C與CHD 事件存在的線性關(guān)系更多地源于流行病學(xué)研討結(jié)果而不是RCTs證據(jù).LDL-C與冠心病危險的對數(shù)直線關(guān)系Log(CHD event rate)LDL cholesterolL

9、og(CHD event rate) vs LDL cholesterol.更為準(zhǔn)確的表達(dá):CHD event rateLDL cholesterolCHD event rate vs LDL cholesterol.Summary Table of Lipid StudiesEvent Rate(%)LDL Cholesterol at End of Follow-up in mg/dLStatins Placebo Fitted line.Summary Table of Lipid StudiesEvent Rate(%)LDL Cholesterol at End of Follow-

10、up in mg/dLStatins PlaceboFitted line(Statins)Fitted line(Placebo)Fitted values.LDL-C目的值新觀念目的值戰(zhàn)略的不利影響：他汀治療缺乏：因基線LDL-C程度未超越目的值而未開場他汀治療，或由于已達(dá)目的值而使他汀未用至理想劑量。循證證據(jù)清楚顯示，在他汀獲益人群中，ASCVD事件是經(jīng)過運(yùn)用最大耐受量他汀降低的，無論基線LDL-C程度如何。非他汀藥物運(yùn)用過度：加用非他汀藥物以到達(dá)目的值，而不是逐漸添加他汀用量至有循證證據(jù)支持的劑量而這些藥物即使能使LDL-C進(jìn)一步降低，也未顯示可進(jìn)一步降低ASCVD事件。.HPS re

11、sultsNo Significant Difference in Relative Benefit of Statin Therapy By Either Baseline LDL or LDL Response Results From the Heart Protection StudyEvent rate ratio (95% Cl).LDL-C目的值新觀念臨床實(shí)例二級預(yù)防假設(shè)一個二級預(yù)防患者接受80mg阿托伐他汀治療，LDL-C為78mg/dl，那么患者曾經(jīng)接受了基于證據(jù)的治療。迄今為止，沒有數(shù)據(jù)顯示在高強(qiáng)度他汀治療根底上加用非他汀藥物可以額外降低心血管風(fēng)險又具有可接受的平安性。不采

12、用LDL-C190mg/dl的家族性高膽固醇血癥在許多情況下，家族性高膽固醇血癥患者無法到達(dá)LDL-C100mg/dl的目的值。例如，一位家族性高膽固醇血癥患者雖然合用了三種降脂藥物，LDL-C也只能降至120mg/dl。雖然這位患者沒能到達(dá)100mg/dl的目的值，但LDL-C下降幅度已超越50%未治療時LDL-C程度為325-400mg/dl。察看性研討數(shù)據(jù)顯示這些患者即使沒有到達(dá)特定的LDL-C目的，心血管事件的風(fēng)險也明顯降低，治療并不是失敗的。.LDL-C目的值新觀念臨床實(shí)例2型糖尿病對于具有危險要素的40-75歲糖尿病患者，運(yùn)用高強(qiáng)度他汀降低LDL-C的潛在獲益是明顯的，應(yīng)首先強(qiáng)調(diào)運(yùn)

13、用可耐受的最大劑量的他汀治療。糖尿病患者的LDL-C程度常低于無糖尿病患者，目的值戰(zhàn)略那么會鼓勵他汀用量低于循證證據(jù)支持的劑量，非他汀藥物那么常被加用來治療高甘油三脂或低HDL-C，而目前缺乏非他汀藥物可降低心血管事件的RCTs證據(jù)。.主要內(nèi)容Focus on ASCVD Risk Reduction: 4 statin benefit groupsA New Perspective on LDLC and/or Non-HDLC GoalsGlobal Risk Assessment for Primary PreventionSafetyRole of Biomarkers and Non

14、invasive TestsFuture Updates to the Blood Cholesterol Guideline.一級預(yù)防總體風(fēng)險評價對沒有臨床ASCVD的白人或黑人男性和女性，引薦運(yùn)用新的匯總隊(duì)列方程式 Pooled Cohort Equations評價其估計(jì)的10年心血管疾病風(fēng)險。Based on traditional risk factors：age, sex, total and HDLcholesterol, treated or untreated systolic BP level, diabetes, and current smokingRace- and s

15、ex-specific, the predicted 10-year ASCVD risks are 2.1% for White women, 3.0% for African-American women, 5.3% for White men, and 6.1% for African-American men.When compared with nonHispanic Whites, estimated 10-year risk for ASCVD is generally lower in Hispanic-American and Asian-American populatio

16、ns and higher in American-Indian populations“以病人為中心,運(yùn)用他汀進(jìn)展心血管一級預(yù)防前，要綜合思索潛在的心血管獲益、負(fù)作用、藥物相互作用及患者志愿。.主要內(nèi)容Focus on ASCVD Risk Reduction: 4 statin benefit groupsA New Perspective on LDLC and/or Non-HDLC GoalsGlobal Risk Assessment for Primary PreventionSafetyRole of Biomarkers and Noninvasive TestsFuture

17、 Updates to the Blood Cholesterol Guideline.平安性具有以下情況的患者較易出現(xiàn)他汀負(fù)作用：多種或嚴(yán)重的伴隨疾病，包括肝腎功能受損之前有他汀不耐受或肌病病史無法解釋的ALT升高超越3倍上限值患者體質(zhì)或合用的藥物影響他汀代謝75歲以上患者有下述特點(diǎn)患者，做高強(qiáng)度他汀治療決策時應(yīng)適當(dāng)調(diào)整：出血性卒中病史亞裔.主要內(nèi)容Focus on ASCVD Risk Reduction: 4 statin benefit groupsA New Perspective on LDLC and/or Non-HDLC GoalsGlobal Risk Assessment

18、 for Primary PreventionSafetyRole of Biomarkers and Noninvasive TestsFuture Updates to the Blood Cholesterol Guideline.生物標(biāo)志物和非侵入性檢查對于不在四類獲益人群的患者，以及尚不明確能否要開場他汀治療的患者，可以參考其他要素來做出治療決策：初始LDL-C160mg/dl或有遺傳性高脂血癥的證據(jù)早發(fā)心血管病家族史男性一級親屬發(fā)病年齡55歲或女性一級親屬發(fā)病年齡66歲高敏C反響蛋白2mg/L冠脈鈣化積分CAC300 Agatston units或其年齡性別種族的第75百分位數(shù)踝臂指數(shù)0.9心血管疾病終身風(fēng)險( lifetime risk )較高.主要內(nèi)容Focus on ASCVD Risk Reduction: 4 statin benefit groupsA New Perspective on LDLC and/or Non-HDLC GoalsGlobal Risk Assessment for Primary PreventionSafetyRole of Biomarkers and Noninvasive TestsFuture Updates to the Blood Cholesterol Guideline.未來