调血脂和抗动脉粥样硬化药物的应用现状和进展趋势

血脂异常主要表现为低密度脂蛋白胆固醇(LDL-C)、三酰甘油(TG)及载脂蛋白B(apoB)升高,高密度脂蛋白胆固醇(HDL-C)及apoA1降低,是导致冠心病,脑卒中和外周血管疾病的最主要危险因子之一.血脂异常也可导致冠状动脉粥样硬化症.虽然目前治疗目标集中在降低LDL-C上,但未来若干年内其他脂肪/脂蛋白和非脂肪因素有可能成为特殊治疗靶向.现对调血脂和抗动脉粥样硬化药物的应用状况和进展趋势作一介绍.     

Comparison of self-reported survey (SHIELD) versus NHANES data in estimating prevalence of dyslipidemia

ABSTRACT

Objectives: The study purpose was to compare the prevalence of dyslipidemia between a self-reported survey, Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD), and survey and laboratory data from National Health and Nutrition Examination Survey (NHANES 1999–2002).

Methods: A SHIELD questionnaire was mailed to 200?000 households representative of US adult population (64% response, n = 211?097 individuals) and included if ever diagnosed with diabetes, high blood pressure or cholesterol problems, high total cholesterol (TC), high bad cholesterol (LDL-C), low good cholesterol (HDL-C), or high triglycerides (TG). In NHANES using a combination of interviewer-administered survey and clinical and laboratory data, dyslipidemia was defined as any one of: TC ≥?240?mg/dL or diagnosis of high cholesterol; TG >?200?mg/dL;LDL-C ≥?160?mg/dL; or HDL-C <?40?mg/dL. NHANES diabetes mellitus definition was doctor diagnosis or fasting glucose >?125?mg/dL and hypertension was elevated blood pressure or taking anti-hypertensive medication. Prevalence of dyslipidemia was determined for SHIELD in 2004 and compared to NHANES 1999–2002. Prevalence of diabetes and hypertension was estimated for broader contextual comparison within cardiometabolic diseases.

Results: In contrast to the prevalence of diabetes (8% in SHIELD and 9% in NHANES, p < 0.01) and hypertension (23% in SHIELD and 29% in NHANES, p < 0.01), dyslipidemia was reported only half as frequently in SHIELD (26%) as in NHANES (53%), p < 0.01. Com­ponents of dyslipidemia were uniformly less in SHIELD than NHANES: high TC = 17 vs. 35%, high LDL-C = 10 vs. 14%, high TG = 7 vs. 17% and low HDL-C = 5 vs. 24%; all comparisons p < 0.01.

Limitations: Differences in survey methodology, non-response and timing may have impacted the comparison of SHIELD to NHANES.

Conclusions: Dyslipidemia prevalence was lower in self-reported SHIELD than the objectively assessed NHANES, with especially low self-report of high TG and low HDL-C. Self-reported prevalence of dyslipidemia may under-report the prevalence based on laboratory data.     

血清脂蛋白(a)及相关血脂指标预测缺血性卒中病人颈动脉斑块风险的临床价值

目的 研究血清脂蛋白(a)[Lp (a)]及相关血脂指标预测缺血性卒中颈动脉斑块风险的临床价值.方法 将河北医科大学第一医院109例缺血性卒中病人纳入研究样本,根据颈动脉内中膜厚度(IMT)分为无斑块组(48例)与斑块组(61例),结合斑块及超声特征将斑块组分为稳定斑块组(34例)与不稳定斑块组(27例),比较三组Lp(a)、三酰甘油(TG)、总胆固醇(TC)、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)水平,分析血脂异常与颈动脉斑块阳性的相关性及血脂异常检测颈动脉斑块的符合率、敏感性及特异性,以一元线性回归分析法分析血脂指标与IMT厚度的相关性,建立Lp(a)对颈动脉斑块的风险预测模型,分析Lp(a)预测颈动脉斑块形成的有效界值.结果 无斑块组、斑块稳定组及斑块不稳定组TG比较差异无统计学意义(P>0.05),无斑块组→斑块稳定组→斑块不稳定组HDL-C呈递减趋势,组间差异有统计学意义(P<0.05),TC、LDL-C、Lp(a)呈递增趋势,组间差异有统计学意义(P<0.05);血脂异常共63例,血脂异常与IMT增厚存在正相关关系(r=0.413,P=0.021),血脂异常诊断颈动脉斑块符合率85.32%(93/109),敏感性88.52%(54/61),特异性81.25%(39/48);一元线性回归分析显示TC、LDL-C、Lp(a)与IMT厚度正相关(R2=0.911、0.741、0.946),HDL-C与IMT厚度负相关(R2=0.356);Lp(a)对颈动脉斑块风险预测模型:ROC曲线下面积0.815,标准误0.047,P=0.000,95%CI=0.723~0.907.最佳截断值为325 mg·L-1,此时敏感性78.3%,特异性93.9%.结论 血脂水平异常可作为颈动脉斑块阳性的辅助预测指标,而Lp(a)可预测颈动脉斑块风险,具有较高的临床价值.     

胰岛素抵抗与冠心病危险因素的相关性分析

目的:探讨胰岛素抵抗(IR)与冠心病常见危险因素之间的关系。方法:采用回顾性研究,整理自2005年4月—2006年8月住院并行冠状动脉造影确诊冠心病的患者资料,分析胰岛素抵抗与冠心病常见危险因素之间的关系。结果:IR组患者高血压发生率、收缩压、体质量指数(BMI)、三酰甘油(TG)、低密度脂蛋白胆固醇(LDL-C)、空腹血糖(FPG)、空腹胰岛素(FINS)、尿酸(UA)高于胰岛素敏感(IS)组,高密度脂蛋白胆固醇(HDL-C)低于IS组(P<0.05或P<0.01);经Spearman相关分析表明HOMA-IR与患者的高血压、收缩压、TG、FINS、FPG、BMI和UA水平呈正相关(r在0.283～0.937,P<0.05或P<0.01),与HDL-C呈负相关(r=-0.455,P<0.01);经多元逐步Logistic回归分析表明HOMA-IR与高血压、收缩压、TG、FINS、FPG、BMI、UA和HDL-C相关。结论:IR患者存在冠心病危险因素的聚集趋势,常合并高血压、肥胖、血脂代谢紊乱、血糖和胰岛素代谢紊乱,IR可能是冠心病的危险因素。     

新疆生产建设兵团60699例成年居民身体质量指数与高血压、糖尿病和血脂异常患病率的相关分析

目的 探讨新疆生产建设兵团成年居民身体质量指数（BMI）与高血压、糖尿病和血脂异常患病率的关系。方法2019年8月至2020年7月采用多阶段整群抽样，以≥18岁新疆生产建设兵团常住居民为调查对象，采用方差分析、偏相关分析和logistic回归分析，研究BMI与高血压、糖尿病和血脂异常患病率的关系。结果 60 699例研究对象中高血压、糖尿病和血脂异常的患病率分别为28.65%(17 384/60 699),10.01%(6 074/60 699),28.32%(17 182/60 699);BMI分层中正常体质量占46.98%，超重占37.80%，肥胖占15.22%；不同BMI分层中病人的血压、血糖和血脂水平差异有统计学意义（P<0.05）；相关性分析中BMI与收缩压、舒张压、空腹血糖、总胆固醇、三酰甘油和低密度脂蛋白胆固醇（LDL-C）呈正相关（P<0.05），与高密度脂蛋白胆固醇（HDL-C）呈负相关（P<0.05）；多因素logistic回归分析显示，超重组的高血压、糖尿病和血脂异常患病风险是正常组的2.07倍、2.02倍和1.88倍；肥胖组的高血压、糖尿病和血...     

宝鸡市 15 岁以上居民血脂异常情况调查分析

目的分析宝鸡市15岁以上人群血脂异常及危险因素流行情况,为制订针对性防控措施提供科学依据。方法采用多阶段整群抽样、问卷调查、体格测量、血脂检测、统计学分析等。结果宝鸡市15岁以上人群血脂异常检出率为69．7％（551／790）,不同类型县区人群血脂异常率比较,差异有统计学意义（P〈0．05）,主要危险因素为体质量指数、血糖、腰围及吸烟。结论宝鸡市15岁以上人群血脂异常情况比较严重,以高甘油三酯血症和低高密度脂蛋白胆固醇血症为主,血脂异常呈年轻化趋势,做好全人群血脂综合防控工作十分重要。     

The role of a new formulation of fenofibric acid in the treatment of mixed dyslipidemia in type 2 diabetes

Diabetes, due to its multifactorial effects, increases the risk of developing cardiovascular disease. Dyslipidemia is an important modifiable risk factor. Mixed dyslipidemia (low high-density lipoprotein cholesterol [HDL-C], elevated triglycerides and a high percentage of small, dense lowdensity lipoprotein cholesterol [LDL-C]) is a common lipid disorder in diabetics and is considered especially atherogenic. Research suggests that in patients with dyslipidemia, combination therapy with fibrates and statins may be more effective than statin monotherapy alone. The choline salt of fenofibric acid (choline fibrate) is indicated for the treatment of mixed dyslipidemia, either as a single treatment or in combination with statin therapy. It does not require first-pass metabolism, but dissociates in the gastrointestinal tract into the pharmacologically active fenofibric acid. This new formulation of fenofibric acid in combination with a low or moderate dose of statin has been shown to be effective in increasing HDL-C and lowering triglycerides beyond that provided by statin monotherapy alone. The ACCORD trial failed to show a mortality or morbidity benefit after combination therapy, although the data suggested that combination therapy may benefit patients with mixed dyslipidemia.     

血脂异常与冠状动脉病变程度的相关性分析

目的：探讨冠状动脉病变与血脂异常的关系。方法：将100例疑似冠心病的患者依据冠状动脉造影结果分为：正常组；1支病变组；2支病变组；3支病变组。同时测定并统计分析血脂各成分与冠状动脉病变之问的关系。结果：各组的总胆同醇（TC）、甘油三酯（TG）差异无显著性。1支病变组，2支病变组在低密度脂蛋白（LDL-C）水平上与正常组比较未见明显增高。但在高密度脂蛋白（HDL-C）水平上，与正常组比较有明显降低且有统计学意义。3支病变组与正常组比较。低密度脂蛋白（LDL-C）明显增高，高密度脂蛋白（HDL-C）明显降低且有统计学意义。结论：血脂各成分与冠状动脉病变相关性分析表明：LDL-C增高和HDL-C降低与冠状动脉病变相关，其中HDL-C指标可能优于LDL-C指标。     

Present-day uses of niacin: effects on lipid and non-lipid parameters

Existing guidelines for the prevention and treatment of coronary artery disease focus on lowering low-density lipoprotein cholesterol (LDL-C) as the primary lipid target. However, there has been increasing interest in raising high-density lipoprotein cholesterol (HDL-C) due to strong evidence linking low HDL-C levels with an increased risk of atherosclerosis. Raising HDL-C levels with lifestyle changes and pharmacologic interventions appear to reduce the risk of coronary artery disease beyond that of lowering LDL-C alone. Niacin has a substantial HDL-C raising effect, and also may beneficially alter total cholesterol, LDL-C and triglyceride levels. Niacin also exhibits antioxidant, anti-inflammatory and other beneficial effects on atherosclerosis. Niacin is safe and effective to use in women, in patients with diabetes mellitus and/or metabolic syndrome, and when used in combination with statins. Niacin has the promise of being a powerful pharmacologic agent in the fight against atherosclerotic disease, although additional clinical studies are required to examine this further.     

Present-day uses of niacin: effects on lipid and non-lipid parameters

Existing guidelines for the prevention and treatment of coronary artery disease focus on lowering low-density lipoprotein cholesterol (LDL-C) as the primary lipid target. However, there has been increasing interest in raising high-density lipoprotein cholesterol (HDL-C) due to strong evidence linking low HDL-C levels with an increased risk of atherosclerosis. Raising HDL-C levels with lifestyle changes and pharmacologic interventions appear to reduce the risk of coronary artery disease beyond that of lowering LDL-C alone. Niacin has a substantial HDL-C raising effect, and also may beneficially alter total cholesterol, LDL-C and triglyceride levels. Niacin also exhibits antioxidant, anti-inflammatory and other beneficial effects on atherosclerosis. Niacin is safe and effective to use in women, in patients with diabetes mellitus and/or metabolic syndrome, and when used in combination with statins. Niacin has the promise of being a powerful pharmacologic agent in the fight against atherosclerotic disease, although additional clinical studies are required to examine this further.     

江门市健康体检人群血脂异常及与慢性非传染性疾病危险因素聚集性的研究

目的 分析江门市健康体检人群血脂异常及与慢性非传染性疾病危险因素聚集性状况.方法 对2010年5-7月健康体检人群3959人分析血脂异常分布情况与高血压、血糖异常、肥胖、高尿酸血症的关系.结果 调查人群高胆固醇血症(TC)、高甘油三酯血症(TG)、高低密度脂蛋白血症(LDL-C)和低高密度脂蛋白血症(HDL-C)的患病...     

Raising high-density lipoprotein cholesterol with reduction of cardiovascular risk: the role of nicotinic acid – a position paper developed by the European Consensus Panel on HDL-C*

SUMMARY

Reduction of low-density lipoprotein cholesterol (LDL-C) is presently the primary focus of lipid-lowering therapy for prevention and treatment of coronary heart disease (CHD). However, the high level of residual risk among statin-treated patients in recent coronary prevention studies indicates the need for modification of other major components of the atherogenic lipid profile. There is overwhelming evidence that a low plasma level of high-density lipoprotein cholesterol (HDL-C) is an important independent risk factor for CHD. Moreover, a substantial proportion of patients with or at risk of developing premature CHD typically exhibit distinct lipid abnormalities, including low HDL-C levels. Thus, therapeutic intervention aimed at raising HDL-C, within the context of reducing global cardiovascular risk, would benefit such patients, a viewpoint increasingly adopted by international treatment guidelines.     

Raising high-density lipoprotein cholesterol with reduction of cardiovascular risk: the role of nicotinic acid--a position paper developed by the European Consensus Panel on HDL-C

Reduction of low-density lipoprotein cholesterol (LDL-C) is presently the primary focus of lipid-lowering therapy for prevention and treatment of coronary heart disease (CHD). However, the high level of residual risk among statin-treated patients in recent coronary prevention studies indicates the need for modification of other major components of the atherogenic lipid profile. There is overwhelming evidence that a low plasma level of high-density lipoprotein cholesterol (HDL-C) is an important independent risk factor for CHD. Moreover, a substantial proportion of patients with or at risk of developing premature CHD typically exhibit distinct lipid abnormalities, including low HDL-C levels. Thus, therapeutic intervention aimed at raising HDL-C, within the context of reducing global cardiovascular risk, would benefit such patients, a viewpoint increasingly adopted by international treatment guidelines. Therapeutic options for patients with low HDL-C include treatment with statins, fibrates and nicotinic acid, either as monotherapy or in combination. Of these options, nicotinic acid is not only the most potent agent for raising HDL-C but is also effective in reducing key atherogenic lipid components including triglyceride-rich lipoproteins (mainly very low-density lipoproteins [VLDL] and VLDL remnants), LDL-C, and lipoprotein(a). The principal features of the atherogenic lipid profile in type 2 diabetes and the metabolic syndrome make them logical targets for nicotinic acid therapy, either alone or in combination with a statin. The lack of comprehensive European data on the prevalence of low HDL-C levels highlights a critical need for education on the importance of raising HDL-C in CHD prevention and treatment. The development of a reliable and accurate assay for HDL-C, as well as clarification of criteria for low and optimal levels of HDL-C in both men and women, constitute critical factors in the reliable identification and treatment of patients at elevated risk of CHD due to low HDL-C. Based on the available evidence, the European Consensus Panel recommends that the minimum target for HDL-C should be 40 mg/dL (1.03 mmol/L) in patients with CHD or with a high level of risk for CHD, including patients at high global risk with type 2 diabetes or the metabolic syndrome.     

Effects of policosanol and lovastatin on lipid profile and lipid peroxidation in patients with dyslipidemia associated with type 2 diabetes mellitus

In this pilot, randomized, double-blind study, we compared the effects of policosanol and lovastatin on lipid profile and lipid peroxidation in patients with dyslipidemia and type 2 diabetes mellitus. After 4 weeks on a cholesterol-lowering diet, 36 patients were randomized to policosanol (10 mg/day) or lovastatin (20 mg/day) tablets o.i.d. for 8 weeks. Policosanol significantly (p < 0.001) lowered serum low-density lipoprotein-cholesterol (LDL-C) (29.9%), total cholesterol (21.1%), triglycerides (13.6%) and the LDL-C/high-density lipoprotein-cholesterol (HDL-C) (36.7%) and total cholesterol/HDL-C (28.9%) ratios and significantly (p < 0.01) increased HDL-C (12.5%). Lovastatin significantly (p < 0.001) lowered LDL-C (25%), total cholesterol (18%), triglycerides (10.9%) and the LDL-C/HDL-C (30.4%) and total cholesterol/HDL-C ratios (23.9%) and significantly (p < 0.01) raised HDL-C (8.3%). Policosanol was more effective (p < 0.05) than lovastatin in reducing both ratios and in increasing (p < 0.05) HDL-C. Policosanol, but not lovastatin, significantly raised the lag time (20.9%) of Cu+2-induced LDL peroxidation and total plasma antioxidant activity (24.2%) (p < 0.05). Both policosanol and lovastatin significantly decreased the propagation rate (41.9% and 41.6% respectively, p < 0.001), maximal diene production (8.3% and 5.7%) and plasma levels of thiobarbituric acid reactive substances (9.7% and 11.5%, p < 0.001). Both treatments were well tolerated. Only one patient in the lovastatin group withdrew from the trial due to adverse events. In conclusion, policosanol and lovastatin administered short term to patients with dyslipidemia secondary to type 2 diabetes were effective in lowering cholesterol and in inhibiting the extent of lipid peroxidation. Policosanol (10 mg/day) was slightly more effective than lovastatin (20 mg/day) in reducing the LDL-C/HDL-C and total cholesterol/HDL-C ratios, in increasing HDL-C levels and in preventing LDL oxidation. Nevertheless, since this was a pilot study, further clinical studies performed in larger sample sizes of diabetic patients are needed for definitive conclusions.     

早发冠心病危险因素和冠状动脉的病变特征

目的探讨早发冠心病患者的危险因素及冠状动脉的病变特征。方法选择早发冠心病128例患者作为观察组,选择同期体检的健康人128例作为对照组,比较两组间的发病因素和冠状动脉的病变特征,分析相关因素。结果两组BMI、高血压、吸烟、肥胖和家族史差异均有统计学意义（均P〈0．05）;观察组Tc、TG、LDL．C、ApoB、Lp和Fib均较对照组升高（均P〈0．05）;观察组HDL—C和ApoAl均较对照组降低（均P〈0．05）。结论家族史、高血压和血脂异常是早发冠心病的独立危险因素,吸烟对早发冠心病起重要作用;早发冠心病单支病变和左前降支病变较多见。     

唐山市946例煤炭从业人员高尿酸血症患病情况分析

目的：了解唐山市煤炭行业从业人员高尿酸血症（HUA）的患病情况和相关危险因素。方法：选取唐山市煤炭行业从业人员共946人,询问一般情况、个人生活习惯、家族疾病史等,测定身高、体质量和血压。取空腹肘正中静脉血检测血尿酸、血糖、总胆固醇（TC）、三酰甘油（TG）、高密度脂蛋白胆固醇（HDL-C）和低密度脂蛋白胆固醇（LDL-C）,并对检测结果进行分析。结果：HUA检出率10.7%,HUA组的体质指数、TG、TC、SBP、DBP高于非HUA组（P<0.05）。HUA组中男性、肥胖、吸烟、饮酒、高血压家族史、高血压、血脂异常者所占比例大于非HUA组（P<0.05）,多因素分析显示性别、肥胖、血脂异常、高血压是HUA的独立危险因素。结论：煤炭行业从业人员HUA检出率较高,脂质代谢异常、高血压及不良生活习惯是其主要危险因素。     

餐后血脂代谢异常与冠状动脉病变严重程度关系研究

目的分析餐后血脂代谢异常与冠状动脉狭窄程度的关系。方法对81例冠状动脉粥样硬化性心脏病（冠心病）患者行冠状动脉造影,按冠状动脉狭窄程度分为对照组、冠心病组,后者又分为1支病变组、2支病变组、3支病变组。同时测定患者空腹及餐后4h血清总胆固醇（TC）、三酰甘油（TG）、高密度脂蛋白胆固醇（HDL-C）、低密度脂蛋白胆固醇（LDL-C）、载脂蛋白A（ApoAI）的含量。结果与对照组比较,冠心病组空腹血清TC浓度显著增高（P〈0.05）,冠心病组餐后4h血清TG、LDL-C浓度显著升高（P〈0.05）,HDL-C浓度显著降低（P〈0.05）。餐后4h血清中TC、TG、LDL-C含量随冠状动脉病变加重而增加,HDL-C、ApoAI含量随冠状动脉病变加重而减少,TC、TG、LDL-C与冠状动脉狭窄程度呈正相关,HDL-C与冠状动脉狭窄程度呈负相关（r值分别为0.078、0.061、0.025和-0.145,P〈0.05）。结论餐后血脂代谢紊乱与冠状动脉狭窄的发生发展有内在的联系,对于预测有无冠状动脉病变及其进展有一定临床意义。     

社区原发性高血压患者血脂代谢状况的调查

目的：了解社区高血压患者血脂代谢状况。方法随机选择青浦区徐泾镇4个居委会295例高血压患者作为研究对象,对其空腹血脂,包括血清总胆固醇（TC）、甘油三酯（TG）、高密度脂蛋白胆固醇（HDL-C）、低密度脂蛋白胆固醇（LDL-C）进行检查并进行统计学分析。结果295例高血压患者中,TC升高占9.8%,TG升高占7.8%,LDL-C升高占7.8%,HDL-C下降占9.5%;血脂边缘异常的患者占很大比例,其中TC边缘升高25.8%,TG边缘升高11.9%,LDL-C边缘升高占22.0%。不同性别高血压患者中,血脂异常率比较,差异有统计学意义（P＜0.05）。结论高血压患者中血脂升高所占比例相对较高,脂代谢边缘升高的患者比例更高,因此,我们在预防心脑血管疾病强调降压的同时必须重视血脂管理。     

高血压/2型糖尿病/2型糖尿病伴高血压血脂分析的评价

目的:糖尿病患者大血管和微血管并发症的发生率都与血管收缩压的变化呈正相关,与血脂的升高也呈正相关,故需提高广大临床工作者对糖尿病伴高血压的认识,建立一套适合于糖尿病患者的科学化,现代化,规范化的降压,降脂方案尤为重要。方法:将住院病人60例分为3组,其中1组为2型糖尿病非高血压组,2组为高血压非糖尿病组,3组为2型糖尿病伴高血压组,另设门诊健康体检者20例为对照组。每组均进行血脂分析,血脂项目包括:甘油三脂(TG)胆固醇(CH)高密度脂蛋白(HDL-C)低密度脂蛋白(LDL-C)载脂蛋白A(ApoA-1)载脂蛋白B(Apo-B)脂蛋白(a)。研究3种疾病与血脂分析的相关性及3种疾病中血脂各项指标浓度变化的评价。结果:①单纯2型糖尿病组中,血脂升高占35%其中TG,CH,LDL-C,升高具非常显著性差异(P<0.01)HDL-C降低具非常显著性差异(P<0.01)LP(a)ApoA-1,Apo-B无显著性变化(P>0.05)。②高血压组中,血脂升高占30%其中TG,CH升高具非常显著性差异(P<0.01)HDL-C,LDL-C,ApoA-1,Apo-B,LP(a).无显著性差异(P>0.05)。③2型糖尿病伴高血压组中,血脂升高占80%其中TG,CH,LDL-C,Apo-B,LP(a)升高均具有非常显著性差异(P<0.01)HDL-C,ApoA-1降低具非常显著性差异(P<0.01)。结论:2型糖尿病伴高血压更易发生脂质代谢紊乱,两种疾病同时发生于一个患者,这种动脉硬化危险因素聚集存在相互影响且作用相互叠加,加速了心血管并发症的发生与发展,大大增强了发生冠心病,脑卒中的危险。