急性心肌梗死患者胆固醇不高者如何使用他汀类药物？

2007年《中国成人血脂异常防治指南》根据中国成人血脂特点,将低密度脂蛋白胆固醇（LDL-C）〈2．08mmol／L（1mmol/L=0．026mg／dL）设定为极高危患者的降脂目标。极高危患者指的是急性冠状动脉综合征或缺血性心血管病合并糖尿病。急性心肌梗死患者是冠状动脉粥样硬化性心脏病（冠心病）的极高危人群,如果胆固醇水平不高,需了解LDL—C的水平。对于LDL-C高于目标值的患者,应积极给予他汀类药物治疗,从而减少心血管事件的发生。     

不同剂量他汀类药物短期治疗后降脂效果及不良反应研究

目的探讨不同剂量他汀类药物短期治疗后降脂疗效的差异,他汀类血药浓度与降脂疗效以及药物不良反应的关系。方法连续入选2010年8月至2011年4月于北京大学人民医院心内科住院治疗且近期未服用他汀类药物的高胆固醇血症患者153例,按随机数字表法分为4组,分别给予辛伐他汀20 mg、40 mg、阿托伐他汀10 mg、20 mg降脂治疗。测量治疗前及治疗1周后晨起空腹血脂水平及治疗1周后血药浓度血脂水平,同时观察治疗期间药物不良反应。结果不同剂量的辛伐他汀与阿托伐他汀用药1周均能有效降低TC及LDL-C水平(均为P<0.01)。与辛伐他汀10 mg组相比,辛伐他汀20 mg组的LDL-C及TC的下降幅度增加了7.1%和3.3%(P=0.156,P=0.104);与阿托伐他汀10 mg组相比,阿托伐他汀20 mg组的LDL-C及TC的下降幅度增加了1.5%和0.5%(P=0.352,P=0.259)。所有高危患者组较极高危患者组的LDL-C达标率更高(71.0%比32.8%,P<0.001)。不同剂量的辛伐他汀与阿托伐他汀用药1周后血药浓度比较,差异均无统计学意义,阿托伐他汀10 mg组的血药浓度与LDL-C下降幅度相关(均为P<0.05)。辛伐他汀与阿托伐他汀的血药浓度与药物不良反应无相关性。结论临床常规剂量范围内,不同剂量的辛伐他汀及阿托伐他汀短期治疗均能有效降低血脂水平。辛伐他汀及阿托伐他汀的血药浓度与药物不良反应无相关性。     

老年血脂异常患者调脂治疗的现状分析

目的分析老年血脂异常患者调脂治疗情况及影响血脂LDL-C达标率的可能因素。方法应用统一的调查表,调查2007年8月～2008年8月在我院住院的607例患者调脂治疗情况,按年龄分老年组(≥60岁,403例)和非老年组(60岁,204例)。对患者进行血脂异常危险分层,以LDL-C为判断标准,计算血脂控制达标率。结果与非老年组LDL-C达标率(36.8%)比较,老年组LDL-C达标率为42.4%,差异无统计学意义(P0.05)。老年组患者中低危、中危、高危和极高危LDL-C达标率分别为100%、77.4%、45.7%和21.5%,差异有统计学意义(P0.01)。血脂异常危险分层、医疗付费方式、有无合并疾病与血脂控制达标率显著相关。结论老年血脂异常患者调脂治疗与2007年新指南标准仍有差距,危险分层越高,达标率相对越低。     

老年患者调脂治疗达标状况分析

目的初步了解2007年血脂异常防治指南颁布后老年患者的调脂治疗达标情况。方法选择2009年2～7月在我院老年病房住院并服用他汀类药物治疗4周以上的男性患者144例,按照2007年中国成人血脂异常防治指南危险分层方案,分为高危组(65例)和极高危组(79例),并按指南规定的不同危险分层血脂控制目标值,判断调脂治疗是否达标,分析可能影响达标率的因素。结果高危组与极高危组患者多数服用阿托伐他汀治疗,平均治疗剂量差异无统计学意义。服药4周后,2组间TC、LDL-C、TG及HDL-C水平差异无统计学意义。TC总达标率为41.7%,LDL-C总达标率为54.9%,TC+LDL-C总达标率为41.7%。高危组TC、LDL-C及TC+LDL-C达标率分别为67.7%、70.8%和66.2%;极高危组达标率分别为20.3%、41.8%和21.5%(P0.05)。多因素logistic回归分析显示,极高危组达标率与年龄、冠心病、高血压、糖尿病、周围血管疾病及糖尿病控制情况无明显相关性。结论目前,老年患者的调脂治疗达标率仍较低,与指南要求存在较大差距,其中的影响因素值得进一步探讨。     

老年患者应用不同类型他汀类药物的疗效及安全性评价

目的观察不同剂量和类型他汀类药物在老年高脂血症患者中应用的疗效与安全性。方法回顾性分析456例老年高脂血症患者服用他汀类药物情况,根据服药情况分为:阿托伐他汀组(169例)、辛伐他汀组(110例)、普伐他汀组(137例)和氟伐他汀组(40例);又根据《中国成人血脂异常防治指南》将患者分为中危(41例)、高危(232例)和极高危(183例)。观察治疗8周后血脂水平及不良反应。结果与治疗前比较,阿托伐他汀组、辛伐他汀组、普伐他汀组和氟伐他汀组治疗8周后血清TC、LDL-C水平均明显降低(P0.05,P0.01)。4组治疗前后血清TG水平差异无统计学意义(P0.05)。阿托伐他汀组、辛伐他汀组治疗8周后血清TC、LDL-C变化率与普伐他汀组、氟伐他汀组比较差异有统计学意义(P0.05)。各组中高危患者服用标准剂量他汀类药物治疗后,LDL-C达标率均在80%以上,极高危患者达标率为44.1%～55.7%。结论多数老年高脂血症患者服用小剂量和(或)标准剂量他汀类药物血脂即可达标。且治疗安全性好,无严重不良反应发生。     

老年患者服用血脂康的疗效与安全性分析

目的:观察我院老年患者应用血脂康的疗效与安全性。方法:回顾性分析我院236例服用血脂康的老年患者,依据2007年中国成人血脂异常防治指南推荐的心血管疾病危险分层方案和血脂控制目标对患者进行危险分层并判断患者血脂水平是否达标,观察患者的血脂达标率、达标剂量及不良反应情况。结果:服用血脂康的老年患者共236例,其中包括心血管疾病中危患者7例、高危者169例、极高危者60例。中危患者LDL-C、非HDL-C及TC达标率均为100%,高危患者LDL-C、非HDL-C及TC达标率分别为71.0%、78.1%及59.2%,极高危患者LDL-C、非HDL-C及TC达标率分别为53.3%、51.7%及16.7%。中、高、极高危患者血脂康平均使用剂量分别为0.9、1.0、0.9g/d。在236例患者中,2.2%出现ALT轻度升高,8.0%出现CK轻度升高,ALT及CK升高均未超过正常上限3倍。结论:老年心血管病中危及高危患者应用血脂康治疗血脂达标率较高,极高危患者血脂达标率偏低,血脂康治疗安全、有效。对于极高危患者血脂康的使用剂量偏低、达标率低的现状应引起重视。     

中国急性心肌梗死患者发病前动脉粥样硬化性心血管疾病危险分层分析

目的:探究急性心肌梗死患者发病前的动脉粥样硬化性心血管疾病(ASCVD)危险分层情况和应用他汀类药物进行预防治疗的现状。方法:纳入2013年1月1日至2016年1月30日入选中国急性心肌梗死注册研究(CAMI)的1型急性心肌梗死患者,依据中国成人血脂异常防治指南(2016年修订版),评估其发病前的ASCVD危险分层情况,并调查不同危险分层患者使用他汀类药物的情况。结果:在30 952例急性心肌梗死患者中,11 950例(38.6%)患者为ASCVD低危人群,5 360例(17.3%)患者为ASCVD中危人群,ASCVD高危、极高危人群分别占25.8%(7 990例)和18.3%(5 652例)。仅5.7%的高危患者服用他汀类药物治疗,低密度脂蛋白胆固醇(LDL-C)达标率为22.4%;极高危患者中仅16.4%应用他汀类药物进行ASCVD二级预防,LDL-C达标率仅18.3%。结论:我国超半数急性心肌梗死患者发病前为ASCVD低中危患者,高危和极高危患者使用他汀类药物进行一级、二级预防的比例均较低。     

依折麦布和辛伐他汀联合应用对急性冠脉综合征患者血脂达标率的影响研究

目的 研究依折麦布联合辛伐他汀对急性冠脉综合征(ACS)患者血脂达标率的影响.方法 入选初次就诊诊断的ACS患者80例,随机分为2组,各40例.辛伐他汀组给予辛伐他汀(40mg/d)治疗,联合组给予辛托伐他汀(40mg/d)和依折麦布(10mg/d)联合治疗,6周后比较两组患者血脂达标率及不良反应.结果 与治疗前相比,两组的总胆固醇、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)、三酰甘油水平均有明显降低;与治疗前比较,联合组的HDL-C水平上升,差异无统计学;LDL-C的调脂幅度和LDL-C的达标率均高于辛伐他汀组.联合组不良反应发生率与辛伐他汀组比较,差异无统计学意义(P＞0.05).结论 依折麦布联合辛伐他汀可以有效治疗ACS患者的血脂,并提高其达标率,优于单用辛伐他汀.依折麦布联合辛伐他汀联合可应用于ACS的初始降脂治疗.     

依折麦布联合辛伐他汀对冠心病及糖尿病患者的血LDL-C达标和安全性观察

目的 观察依折麦布联合辛伐他汀对冠心病及糖尿病患者血LDL-C达标率和安全性。方法选择血LDL-C未达标的冠心病及糖尿病患者46例,随机分成依折麦布（10mg/d）联合辛伐他汀（20mg/晚）组（联合治疗组）24例和他汀加倍治疗组22例（给予辛伐他汀40mg/晚）。观察两组患者降脂药物治疗后血脂水平变化及第4周、8周、12周时患者血LDL-C达标率、药物不良反应等。结果在降脂治疗第4、8和12周,联合用药组血LDL-C达标率均高于他汀加倍治疗组,第8、12周时两组患者达标率比较有显著统计学差异（P〈0.01）。药物治疗12周时,两组患者血脂水平较治疗前均有改善,血LDL-C和TC水平与同组治疗前比较差异有统计学意义（P〈0.01～0.05）;两组患者药物治疗12周后血LDL-C和TC水平比较亦有显著统计学差异（P〈0.01）。联合用药组患者均能耐受降脂治疗,他汀加倍治疗组中有2例（9.1%）患者因不良反应出现减量或停药。结论依折麦布联合辛伐他汀治疗较单纯加大辛伐他汀剂量治疗更能提高患者血LDL-C达标率,且具有良好耐受性。     

选择性胆固醇吸收抑制剂临床应用中国专家共识(2011版)

血脂异常与心血管疾病密切相关.过去10余年中,国内外先后完成了一系列里程碑式的血脂干预研究.这些研究结果有力证实,积极降低胆固醇水平可以显著降低心血管病高危人群的心血管事件发生率,因而降胆固醇达标被视为防治心血管疾病的核心策略.虽然确凿证据表明,他汀类药物在动脉粥样硬化性心血管疾病一、二级预防中具有重要地位,合理应用此类药物可显著降低心血管疾病的发病率与病死率,然而在临床实践中,许多患者在接受了较大剂量他汀类药物治疗后其胆固醇水平仍不能达到目标值,另有一些患者由于种种原因不能耐受他汀类药物治疗,这已成为提高血脂达标率的重要羁绊.中围第二次血脂治疗现状调研结果显示,高危、极高危心血管病患者LDL-C达标率仅为31％和22％,这一现状提示我们应采取更多的有效手段对胆固醇水平进行干预,以期给患者带来尽可能多的临床益处.降胆固醇新药选择性胆固醇吸收抑制剂的问世为降低胆固醇治疗提供了一种新手段.     

Relative atherogenicity and predictive value of non-high-density lipoprotein cholesterol for coronary heart disease

Although low-density lipoprotein cholesterol (LDL-C) is a well-established atherogenic factor for coronary heart disease, it does not completely represent the risk associated with atherogenic lipoproteins in the presence of high triglyceride (TG) levels. Constituent lipoproteins constituting non-high-density lipoprotein cholesterol (non-HDL-C) include atherogenic TG-rich lipoproteins, cholesteryl ester-enriched remnants of TG-rich lipoproteins, and lipoprotein(a). Recent observational and intervention studies suggest that the predictive value of non-HDL-C for cardiovascular risk and mortality is better than low-density lipoprotein cholesterol and that non-HDL-C correlates highly with plasma apolipoprotein B levels. Currently, the National Cholesterol Education Program Adult Treatment Panel III guidelines identify non-HDL-C as a secondary target of therapy in patients with TG elevation (> or =200 mg/dl) after the attainment of LDL-C target goals. In patients with coronary heart disease or coronary heart disease risk equivalents, an optional non-HDL-C goal is <100 mg/dl. To achieve the non-HDL-C goal, statin therapy may be intensified or combined with ezetimibe, niacin, a fibrate, or omega-3 fatty acids. In conclusion, non-HDL-C remains an important target of therapy for patients with elevated TGs, although its widespread adoption has yet to gain a foothold among health care professionals treating patients with dyslipidemia.     

第二次中国临床血脂控制达标率及影响因素多中心协作研究

目的了解我国临床血脂控制的最新现状,指导临床血脂异常防治实践。方法在全国21家省部级医院和6家地县级医院中,查阅2004年1月1日至2006年2月28日间开始服调脂药物,且同一药物同一剂量维持≥2个月的2237名患者病例资料,依据美国2004年国家胆固醇教育计划（NCEP）成人治疗组第三次报告（ATPⅢ）及《中国成人血脂异常防治指南》标准计算血脂控制达标率。结果（1）在符合任一血脂防治建议／指南的药物起始治疗标准的2094例患者中,80％来自省部级医院,60％为60岁以上,57％有胆固醇升高,15％无血脂异常,68％合并冠心病等动脉粥样硬化性疾病,75％合并高血压,80％为高危和极高危患者,84％使用他汀类药物,83％采取了不同程度的饮食治疗。（2）依据美国2004年NCEPATPⅢ最新报告,总达标率为34％,低危组、中危组、中高危组、高危组和极高危组达标率分别为85％、78％、61％、31％和22％,差异有统计学意义（趋势性检验P〈0．001）;依据我国新的《成人血脂异常防治指南》,总达标率为50％,低危组、中危组、高危组和极高危组达标率分别为91％、77％、49％和38％,组间差异及趋势性检验均有统计学意义（P〈0．001）。（3）联合用药者达标率为51％,单用他汀类35％,贝特类23％,烟酸类24％,其他类28％,组间差异有统计学意义（P〈0．001）。（4）对1808例服用他汀类药物患者的多元logistic回归分析表明,他汀类药物剂量（高剂量比低剂量,OR=1．72,95％CI：1．15—2．58）、危险分层（极高危比低危,OR=0．02,95％CI：0．01—0．03）、基线LDL-C[每升高0．259mmol／1410mg／d1）,OR=0．83,95％CI：0．80—0．86]和性别（女性比男性,OR=0．77,95％CI：0．60—0．99）等是影响达标率的主要因素。结论我国目前调脂药物的应用对象发生了很大变化,调脂治疗的目的已不单纯是为了降低胆固醇。临床血脂控制状况与各防治指南要求相距仍甚远,特别是高危和极高危患者。要进一步改善我国临床血脂控制状况,药物种类、药物剂量、联合治疗和治疗性生活方式改变等多方面均需要进一步提高。     

Cardiovascular disease risk of type 2 diabetes mellitus and metabolic syndrome: focus on aggressive management of dyslipidemia

Type 2 diabetes mellitus and the closely related metabolic syndrome markedly increase the risk of cardiovascular disease a major contributor is the dyslipidemia. Recent studies and new national guidelines suggest these very high risk patients with cardiovascular disease achieve optional low density lipoprotein cholesterol (LDL-C) level of less than 70 mg/dl. In addition there may be no threshold to begin therapeutic lifestyle change and pharmacologic therapy to reduce LDL-C by 30-40%. Although randomized controlled trials with statins indicate that LDL reduction clearly reduces cardiovascular risk in these patients, the typical dyslipidemia of type 2 diabetes mellitus is also characterized by low high density lipoprotein cholesterol (HDL-C) levels, increased triglyceride-rich lipoproteins and small dense LDL, as well as increased postprandial lipemia. The later lipoproteins increase non-HDL-C levels. In order to address these abnormalities it may be necessary to utilize combined approaches with a fibrate or nicotinic acid, or other agents with statins to help reduce risk beyond statins. In addition, supervised, therapeutic life-style change is often underutilized therapy in patients with established coronary artery disease. This review will focus on maximizing the treatment of dyslipidemia in type 2 diabetes and the metabolic syndrome and discuss the evidence based studies and new developments in the management in these very high risk patients.     

A comparison of non-HDL and LDL cholesterol goal attainment in a large, multinational patient population: The Lipid Treatment Assessment Project 2

ObjectiveThis study evaluated the success in attaining non-HDL-cholesterol (non-HDL-C) goals in the multinational L-TAP 2 study.Methods9955 patients ≥20 years of age with dyslipidemia on stable lipid-lowering therapy were enrolled from nine countries.ResultsSuccess rates for non-HDL-C goals were 86% in low, 70% in moderate, and 52% in high-risk patients (63% overall). In patients with triglycerides of >200 mg/dL success rates for non-HDL-C goals were 35% vs. 69% in those with ≤200 mg/dL (p < 0.0001). Among patients attaining their LDL-C goal, 18% did not attain their non-HDL-C goal. In those with coronary disease and at least two risk factors, only 34% and 30% attained respectively their non-HDL-C and LDL-C goals. Rates of failure in attaining both LDL-C and non-HDL-C goals were highest in Latin America.ConclusionsNon-HDL-C goal attainment lagged behind LDL-C goal attainment; this gap was greatest in higher-risk patients.     

The relationship between non-HDL cholesterol and other lipid parameters in Japanese subjects

Plasma non-HDL cholesterol (HDL-C) concentration that is simply estimated from plasma total cholesterol and HDL-C concentrations, without the influence of plasma triglyceride concentration, has been included as a therapeutic target for hypertriglyceridemic patients in the most recent National Cholesterol Education Program (NCEP) recommendations. In the present study, we estimated plasma non-HDL-C concentration in Japanese subjects to clarify the correlation of plasma non-HDL-C to other plasma lipid concentrations, and to evaluate the NCEP recommendation. Plasma non-HDL-C concentration has a positive correlation with low-density lipoprotein cholesterol (LDL-C) and triglyceride concentrations. From our analysis, 140 mg/dl of plasma LDL-C concentration, which is the level for the diagnosis of hyper-LDL cholesterolemia, corresponds to 169 mg/dl of non HDL-C concentration. The relationship between plasma non-HDL-C and LDL-C concentrations in Japanese subjects is quite similar to that described in the NCEP guideline. Thus, we suggest that non-HDL-C is a useful risk marker in Japan, as recommended by the NCEP.     

不同指南评价我国临床血脂异常达标率差别的研究

目的 比较不同指南评价我国临床血脂异常达标率的差异,深入理解"中国成人血脂异常指南"(简称指南)与国内外相关指南的异同,促进指南更好地推广和应用.方法 对"第二次中国临床血脂控制现状多中心协作研究"调查的2094例患者,分别依据2007年发布的指南与1997年的"血脂异常防治建议"(简称建议)、美国2004年更新的国家胆固醇教育计划成人治疗组第三次报告(简称ATPⅢ)计算LDL-C目标值的达标率.结果 (1)依据建议、ATPⅢ和指南,总达标率分别为62%、34%和50%.(2)以指南为参照,全部极高危和40%高危患者被建议低估;低、中和高危患者各有40%以上被ATPⅢ高估.(3)指南与建议达标率差异中,90%由危险分层不同所致;ATPⅢ与指南达标率差异中,约30%由危险分层不同所致,70%由治疗目标值不同所致.结论 应用不同指南为依据,达标率差异明显.指南较建议危险分层更加积极,较ATPⅢ简单实用.指南更适合在我国人群使用,应大力推广.     

Non-HDL cholesterol as a predictor of carotid atherosclerosis in the elderly

The aim of the present study was to evaluate sclerotic lesions of the common carotid artery by ultrasonography in 921 in-patients aged 65 years and older (77 +/- 7 years) and investigate whether lipid levels were associated with carotid atherosclerosis. In men, an increased risk for carotid atherosclerosis was associated with increased levels of low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol (non-HDL-C). Compared to men with the lowest tertile of LDL-C levels (< 83.4 mg/dl), the adjusted odds ratio was 2.502 (95% confidence interval: 1.426-4.390) in those with the middle tertile (83.4-115.2 mg/dl), and 2.688 (1.509-4.790) in those with the highest tertile ( > 115.2 mg/dl). Like the LDL-C level, the non-HDL-C level showed a positive and linear relationship with carotid atherosclerosis. Compared to men with the lowest tertile of non-HDL-C levels ( < 101 mg/dl), the adjusted odds ratio was 2.881 (1.633-5.081) for those with the middle tertile (101-135 mg/dl), and 2.990 (1.651-5.415) for those with the highest tertile ( > 135 mg/dl). Similarly, in women, an increased risk for carotid atherosclerosis was also positively and linearly associated with LDL-C and non-HDL-C. The Non-HDL-C level is a potential predictor of risk for carotid atherosclerosis in the elderly.     

Non-HDL cholesterol is a better target for predicting periprocedural myocardial injury following percutaneous coronary intervention in type 2 diabetes

Objective: Non-HDL cholesterol (non-HDL-C) has recently been recommended as a first target for dyslipidemia management. We previously reported that LDL cholesterol (LDL-C) and non-HDL-C levels were similarly associated with periprocedural myocardial injury (PMI) following percutaneous coronary intervention (PCI) in patients with coronary artery disease. Here we investigated the comparative prognostic value of non-HDL-C and LDL-C for PMI following PCI in type 2 diabetes (T2D). Methods: We prospectively enrolled 1194 consecutive T2D patients with normal preprocedural cTnI undergoing PCI. Patients were divided into the two groups: group A [glycated hemoglobin (HbA1c) < 7%, n = 567] and group B (HbA1c ≥ 7%, n = 627). PMI was evaluated by cTnI analysis within 24 h. The relationship of preprocedural non-HDL-C and LDL-C levels with peak cTnI values after PCI was examined. Results: Patients in group B, with higher preprocedural non-HDL-C levels, had higher postprocedural cTnI levels (β = 0.102, P = 0.011). In the multivariable model, a 1-SD increase in non-HDL-C produced a 30% and 33% increased risk of postprocedural cTnI >3 × upper limit of normal (ULN) and >5 × ULN in group B, respectively. However, neither LDL-C nor group A patients were affected. Furthermore, patients with non-HDL-C levels ≥130 mg/dl compared with non-HDL-C levels ≤100 mg/dl were associated with a 83.3% and 71.7% increased risk of postprocedural cTnI >3 × ULN and >5 × ULN in group B, respectively. Conclusions: In poorly-controlled diabetic patients (HbA1c ≥ 7%) undergoing PCI, non-HDL-C but not LDL-C was independently associated with and increased risk of PMI, and non-HDL-C levels ≥130 mg/dl had a worse PMI risk profile compared with non-HDL-C levels <100 mg/dl.     

非高密度脂蛋白胆固醇可以替代低密度脂蛋白胆固醇吗?

非高密度脂蛋白胆固醇(non-HDL-C)等于总胆固醇减去高密度脂蛋白胆固醇.流行病学研究认为,在糖尿病、甘油三酯过高和低密度脂蛋白胆固醇(LDL-C)过低的人群中,non-HDL-C比LDL-C更能反映动脉粥样硬化性心血管疾病的发病风险,预测能力更强.对于动脉粥样硬化性心血管疾病患者,non-HDL-C的目标值已被写...