JACC:非他汀疗法降低ASCVD风险患者LDL-C专家共识要点

2016-07-21 broccoli MedSci原创

近日,美国心脏病学院在JACC杂志上(美国心脏病学会杂志)发布了关于在动脉粥样硬化性心血管疾病风险(ASCVD) 人群中使用非他汀类药物降低LDL-C的专家共识。 指南要点如下: 1、此专家共识的目的根据近期的临床试验证据解决现有的推荐对于解决ASCVD高风险亚组中降低LDL-C的不足。 2、2013年ACC/AHA胆固醇指南识别了他汀类药物降低ASCVD风险的4类主

近日,美国心脏病学院在JACC杂志上(美国心脏病学会杂志)发布了关于在动脉粥样硬化性心血管疾病风险(ASCVD) 人群中使用非他汀类药物降低LDL-C的专家共识。

指南要点如下:

1、此专家共识的目的根据近期的临床试验证据解决现有的推荐对于管理ASCVD高风险亚组中降低LDL-C的不足。

2、2013年ACC/AHA胆固醇指南识别了他汀类药物降低ASCVD风险的4类主要获益人群组:(1)≥21岁的临床ASCVD;(2)≥21岁,LDL-C ≥190 mg/dl;(3)40-75岁非ASCVD人群,但患有糖尿病和LDL-C 70-189 mg/dl;(4)40-75岁无ASCVD或糖尿病,LDL-C 70-189 mg/dl,使用汇集队列方程计算得ASCVD10年风险≥7.5%。

3、2013年指南建议使用强效或中效他汀疗法进行一级或二级预防,根据副反应,高龄、药物相互作用或并发症进行必要的剂量调整。

4、当前的指南共识是基于2013年指南的基础上,结合新近的烟酸,依泽麦布,最近批准的PCSK9的抑制剂,alirocumab和evolocumab的临床试验数据。

5、专家共识解决了3个问题,包括:(1)哪些人群需考虑非他汀治疗?(2)哪些情况下需考虑非他汀治疗,如LDL-C降低值(LDL-C减少的比率或变化范围)少于多少期望值,或不合适时,对于真实的他汀不耐受患者有哪些治疗选择?)(3)如果加用非他汀治疗,应该如何使用?

6、所有非他汀治疗的建议包括确保患者遵循健康的生活方式。

7、与2013年指南一致,在开始使用降脂治疗后,应定期检测空腹LDL-C水平,之后每3-12个月检测一次。

8、对于可疑他汀耐受,应暂时停用他汀治疗、减少剂量、再次用药最好选择2-3种不同代谢通路的他汀,若终身服药可间隔(1-3x周)再次服药。

9、对高风险人群,如现存在ASCVD或LDL-C≥190 mg/dl,若应用最大耐受剂量他汀治疗后,仍无法实现LDL-C降低>50%,可考虑应用非他汀药物。

10、加用非他汀治疗时,应考虑其他的风险因素,包括,绝对LDL-C水平、可行的安全和耐受性的科学证据、花费、服药和药物保存的便利性、药物负担、给药途径、基于证据的疗法潜在的危害、重要的是,患者的意愿。指南强调LDL-C水平并不是加药的严格触发点,但这应作为患者整体临床情况需考虑的环节。

11、他汀耐受的高风险人群应考虑转诊给血脂专家和登记营养师,并强烈推荐给有家族性胆固醇增多症的患者。

12、在一项急性冠脉综合症患者试验中,中等剂量的他汀加依折麦布表现出安全性、耐受性及疗效良好,对大多数患者,依折麦布是首选的非他汀类药物。

13、 胆汁酸螯合剂(BAS) 是依折麦布不耐受患者的二线治疗选择,但应避免在甘油三酯水平>300 mg/dl者中应用。

14、对临床ASCVD或家族性高胆固醇血症(FH)患者,若最大耐受剂量他汀及依折麦布治疗后仍无法达到治疗目标,可考虑应用Alirocumab和evolocumab(PCSK9抑制剂)。但由于缺乏上述药物长期安全性及有效性的证据,尚不推荐其用于非FH患者的一级预防。

15、对于纯合子高胆固醇血症(HoFH)患者,强烈推荐将其转诊给血脂专家,可选择他汀、非他汀类药物,包括依折麦布、BAS,必要时可选择洛美他派、米泊美生及LDL血浆置换术。目前,LDL血浆置换术也被批准用于治疗杂合子家族性高胆固醇血症。

原始出处:

Melvyn Rubenfire, MD, FACC; Donald M. Lloyd-Jones, MD, FACC,Expert Consensus on Role of Non-Statin Therapies for LDL-C Lowering for Management of ASCVD Risk ,JACC,Jun 29, 2016 

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content=<a href='/topic/show?id=58b810e5814' target=_blank style='color:#2F92EE;'>#LDL#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10758, encryptionId=58b810e5814, topicName=LDL)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=382c3719677, createdName=zhwj, createdTime=Sat Jul 23 11:48:00 CST 2016, time=2016-07-23, status=1, ipAttribution=)]
    2017-07-01 quxin068
  4. 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content=<a href='/topic/show?id=58b810e5814' target=_blank style='color:#2F92EE;'>#LDL#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10758, encryptionId=58b810e5814, topicName=LDL)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=382c3719677, createdName=zhwj, createdTime=Sat Jul 23 11:48:00 CST 2016, time=2016-07-23, status=1, ipAttribution=)]
    2017-04-09 hbwxf
  5. 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content=<a href='/topic/show?id=58b810e5814' target=_blank style='color:#2F92EE;'>#LDL#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10758, encryptionId=58b810e5814, topicName=LDL)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=382c3719677, createdName=zhwj, createdTime=Sat Jul 23 11:48:00 CST 2016, time=2016-07-23, status=1, ipAttribution=)]
    2016-09-20 1e10c84am36(暂无匿称)

    文章很好,非常有益

    0

  6. 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content=<a href='/topic/show?id=58b810e5814' target=_blank style='color:#2F92EE;'>#LDL#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10758, encryptionId=58b810e5814, topicName=LDL)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=382c3719677, createdName=zhwj, createdTime=Sat Jul 23 11:48:00 CST 2016, time=2016-07-23, status=1, ipAttribution=)]
    2016-09-13 舒心和人

    学习新知识,补充医学营养,感谢分享

    0

  7. 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content=<a href='/topic/show?id=58b810e5814' target=_blank style='color:#2F92EE;'>#LDL#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10758, encryptionId=58b810e5814, topicName=LDL)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=382c3719677, createdName=zhwj, createdTime=Sat Jul 23 11:48:00 CST 2016, time=2016-07-23, status=1, ipAttribution=)]
    2016-07-23 午夜星河

    很有必要学习

    0

  8. 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content=<a href='/topic/show?id=58b810e5814' target=_blank style='color:#2F92EE;'>#LDL#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=10758, encryptionId=58b810e5814, topicName=LDL)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=382c3719677, createdName=zhwj, createdTime=Sat Jul 23 11:48:00 CST 2016, time=2016-07-23, status=1, ipAttribution=)]
    2016-07-23 doctorzheng
  9. 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