冠心病介入治疗患者非高密度脂蛋白胆固醇达标情况与预后的关系研究

背景　低密度脂蛋白胆固醇（LDL-C）是冠心病的一个重要危险因素，多数国际指南一致推荐将LDL-C作为高胆固醇血症患者的主要治疗目标，但是否应同时使用LDL-C和非高密度脂蛋白胆固醇（non-HDL-C）作为心血管疾病二级预防的指标在国内外仍有争议。目的　探讨non-HDL-C达标情况与冠心病患者经皮介入冠状动脉治疗（PCI）术后不良心血管事件再发的关系，并比较non-HDL-C和LDL-C达标情况对冠心病患者远期预后的预测价值。方法　于2019年4月对2002—2008年因冠心病行PCI治疗的665例患者随访3年的资料进行分析，根据二级预防6个月后的血脂（non-HDL-C、LDL-C）达标情况进行分组，采用Kaplan-Meier生存曲线、Log-Rank检验和Cox比例风险回归模型分析血脂达标情况与终点事件〔主要心血管不良事件（MACE）〕的关系。结果　在真实世界里，665例冠心病患者在PCI术后经过6个月的二级预防后，分别有25.71%（171/665）、27.07%（180/665）的患者达到了指南推荐LDL-C或non-HDL-C的标准，有17.29%（115/665）的患者LDL-C和non-HDL-C水平同时达标。LDL-C达标组与不达标组MACE发生率分别为32.7%（56/171）、35.8%（177/494）；non-HDL-C达标组与不达标组的MACE发生率分别为25.6%（46/180）、38.6%（187/485）。LDL-C达标组与不达标组二者风险曲线未见明显差异（P=0.545）；non-HDL-C达标组的MACE累积发病率明显低于non-HDL-C不达标组（P=0.010）；仅non-HDL-C达标组与仅LDL-C达标组相比，差异无统计学意义（P=0.127）。采用Cox比例风险回归分析校正年龄、性别、BMI、吸烟史、冠心病类型、共病情况等传统风险因子后发现，与LDL-C达标组相比，LDL-C不达标组的HR为1.16〔95%CI（0.83，1.61），P=0.386〕；与non-HDL-C达标组相比，non-HDL-C不达标组远期MACE发生风险较高，HR为 1.61〔95%CI（1.12，2.30），P=0.009〕。结论　冠心病PCI术后患者远期心血管不良事件发生风险与non-HDL-C达标与否有关，而与LDL-C治疗达标情况无关，因此，non-HDL-C可能是较LDL-C更适合的冠心病PCI术后血脂异常治疗监测靶点。

Relationship between Non-high-density Lipoprotein Cholesterol Goal Attainment and Prognosis in Patients with Coronary Heart Disease after Percutaneous Coronary Intervention

Background Low-density lipoprotein cholesterol(LDL-C)is one of the important risk factors for coronary heart disease(CHD).Most international guidelines consistently recommend LDL-C as the main treatment target for patients with hypercholesterolemia.However,whether LDL-C and non-high-density lipoprotein cholesterol(non-HDL-C)should be used simultaneously as indicators of secondary prevention of cardiovascular diseases is still controversial at home and abroad.Objective To investigate the relationship between goal attainment of non-HDL-C and recurrence of adverse cardiovascular events in patients with CHD after percutaneous coronary intervention(PCI),and to compare the predictive value of the goal attainment of non-HDL-C and LDL-C in the long-term prognosis of patients with CHD.Methods A total of 665 patients who underwent PCI for CHD from 2002 to 2008 were followed up for three years in April 2019.The patients were divided into groups according to the goal attainment of blood lipid indicators(non-HDL-C,LDL-C)after six months of secondary prevention.Kaplan-Meier survival curve,Log-Rank test and Cox proportional hazards regression model were used to analyze the relationship between goal attainment of blood lipid indicators and major adverse cardiovascular events(MACE).Results In the real world,a relatively small number of CHD patients could meet the standard of blood lipid indicators after six months of secondary prevention after PCI.25.71%(171/665)and 27.07%(180/665)of patients met the criteria recommended in the guidelines for LDL-C and non-HDL-C,and only 17.29%(115/665)of patients met the criteria of both LDL-C and non-HDL-C at the same time.The incidence of MACE was 32.7%(56/171)in LDL-C standard group and 35.8%(177/494)in LDL-C non-standard group.The incidence of MACE was 25.6%(46/180)in non-HDL-C standard group and 38.6%(187/485)in non-HDL-C non-standard group.There was no significant difference in risk curve between the LDL-C standard group and the non-standard group(P=0.545);the cumulative incidence rate of MACE in the non-HDL-C standard group was significantly lower than that in the non-HDL-C non-standard group(P=0.010);there was no significant difference between the only non-HDL-C standard group and only LDL-C standard group(P=0.127).After adjusting the traditional risk factors such as age,gender,BMI,smoking history,coronary heart disease type and comorbidity by Cox proportional risk regression analysis,it was found that compared with LDL-C standard group,HR of LDL-C non-standard group was 1.16〔95%CI(0.83,1.61),P=0.386〕;compared with non-HDL-C standard group,non-HDL-C non-standard group had higher risk of mace in the long term,HR was 1.61〔95%CI(1.12,2.30),P=0.009〕.Conclusion Non-HDL-C goal attainment is significantly associated with longterm MACE of CHD patients after PCI,while LDL-C has nothing to do with this.Therefore,non-HDL-C may be a more suitable monitoring indicator for dyslipidemia therapy in CHD patients after PCI than LDL-C.