美国新版胆固醇指南十大要点:极高危患者LDL-C不能达到<1.8 mmol/L时,应依次使用依折麦布和PCSK9抑制剂

2018-11-11 文韬 中国循环杂志

在美国心脏协会(AHA)2018年学术年会上,新版胆固醇指南公布。新版指南进一步支持胆固醇“低一点,好一点”的理论。

在美国心脏协会(AHA)2018年学术年会上,新版胆固醇指南公布。新版指南进一步支持胆固醇“低一点,好一点”的理论。

该指南共121页、72项推荐,其中29个一类推荐,26个IIa类推荐,14个IIb类推荐和3个III类推荐。

“新版指南强调了健康生活、改变生活方式和预防的重要性。“美国心脏协会主席Ivor Benjamin说,“任何年龄的胆固醇升高都会增加患病风险。即使是年轻人,也应遵循健康的生活方式,理解并保持健康的胆固醇水平。”

以下为该指南的10大要点:

1、所有人都应在整个生命过程中坚持健康生活方式。

健康生活方式可以减少所有年龄段的动脉粥样硬化性血管疾病(ASCVD)风险。

年轻人采取健康的生活方式可以减少危险因素,是降低ASCVD风险的基础。

对于20~39岁的年轻人,评估终身风险有助于临床医生与患者讨论血管病的预防,并强调坚持健康的生活方式。

在所有年龄组中,治疗性生活方式是代谢综合征的主要干预措施。

2、对于临床ASCVD患者,建议使用高强度他汀,或可耐受的最大剂量他汀类,以降低低密度脂蛋白胆固醇(LDL-C)。

应用他汀使LDL-C降低越多,风险就能降低越大。应使用最大耐受剂量他汀类药物,使LDL-C水平降低≥50%。

3、对于极高危ASCVD患者,如果LDL-C不能达到70 mg/dL(1.8 mmol / L),应考虑在他汀药物的基础上使用非他汀类降脂药物。

极高危是指包括多种严重ASCVD事件或1种严重ASCVD事件伴多种危险情况。

对于极高危ASCVD患者,如果最大耐受剂量的他汀仍不能将LDL-C降至70 mg/dL(≥1.8 mmol/L)以下时,使用依折麦布是合理的。

对于极高危患者,服用最大耐受剂量的他汀和依折麦布后,LDL-C仍然≥70 mg/dL(≥1.8 mmol/L)者,使用PCSK9抑制剂是合理的,但其长期安全性(>3年)仍不确定。

4、对于严重原发性高胆固醇血症 [ LDL-C≥190 mg/ dL (≥4.9 mmol/ L) ],可直接开始使用高强度他汀,不需计算10年ASCVD风险。

如果LDL-C水平仍然≥100 mg/dL(≥2.6 mmol/L),使用依折麦布是合理的。

如果他汀加依折麦布后LDL-C水平仍然≥100 mg/dL(≥2.6 mmol/L)且有多重危险因素ASCVC风险增高的患者,可考虑使用PCSK9抑制剂,尽管其长期安全性(>3年)仍不确定。

5、对于40~75岁糖尿病且LDL-C≥70 mg/dL(≥1.8 mmol/L)的患者,可在不计算10年ASCVD风险的情况下开始中等强度他汀类药物治疗。

对于风险较高的糖尿病患者,特别是那些有多重危险因素或50~75岁的患者,使用高强度他汀将LDL-C降低≥50%是合理的。

6、对于40~75岁需要ASCVD一级预防的成人,在启用他汀前应讨论风险。

应讨论危险因素(例如,吸烟、血压升高、LDL-C、糖化血红蛋白,以及计算的10年ASCVD风险);是否存在使危险增加的因素;生活方式改善和他汀类药物治疗的潜在益处;潜在的不利影响和药物相互作用;他汀的费用;患者偏好和价值观。

7、对于40~75岁无糖尿病且LDL-C水平≥70 mg/dL(≥1.8 mmol/L)的成年人,10年ASCVD风险≥7.5%,在讨论后倾向于于使用他汀时,开始使用中等强度他汀。

特别是如果有增加危险的因素,则倾向于使用他汀。如果风险状态不确定,可考虑使用冠状动脉钙化(CAC)来判断。

如果需要他汀,将LDL-C降低≥30%,如果10年风险≥20%,则将LDL-C降低≥50%。

8、对于无糖尿病的40~75岁的10年风险7.5%~19.9%(中度风险)的成年人,如果存在增加危险的因素,倾向于启动他汀。

增加危险的因素包括:早发ASCVD的家族史;LDL-C持续性≥160 mg/dL(≥4.1 mmol/L);代谢综合征;慢性肾病;先兆子痫或过早绝经史(年龄<40岁);慢性炎症性疾病(例如:类风湿性关节炎、牛皮癣或慢性HIV);高危民族(如南亚人);甘油三酯持续≥175 mg/dL(≥1.97 mmol/L);载脂蛋白B≥130 mg/ dL,高敏C-反应蛋白≥2.0 mg/L,踝肱指数<0.9,脂蛋白(a)≥50 mg/dL或125 nmol/L,尤其是脂蛋白(a)较高。

对于10年风险为5%~7.5%(临界风险)者,在有增加危险的情况下,倾向于应用他汀。

9、40~75岁无糖尿病且LDL-C 70~189 mg/dL(1.8~4.9 mmol/ L)的成人中,10年ASCVD风险7.5%~19.9%,如果关于他汀类药物治疗的决定不确定,可考虑检查CAC。

如果CAC为零,对于没有吸烟、糖尿病和早发ASCVD家族史者,可不用或延迟他汀类药物治疗。

CAC评分为1~99者,倾向于使用他汀,特别是对于≥55岁的患者。

如果CAC评分≥100 或≥75th百分位,则需要服用他汀,除非讨论后患者不同意。

10、启用他汀或剂量调整后4~12周后复查血脂,观察LDL-C百分比降幅,并评估他汀和生活方式的依从性,根据需要每3~12月复查一次。

通过与基线相比降低LDL-C的百分比来定义对生活方式和他汀类药物治疗的反应。对于极高危ASCVD患者中,如果他汀达到最大剂量时LDL-C≥70 mg/dL(≥1.8  mmol/L),应启动非他汀药物治疗。

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    2019-06-18 FukaiBao
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    2019-10-22 jklm09
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    2019-09-18 Tamikia
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    2018-11-13 zhwj
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