Cardiovasc Diabetol:150万人血浆甘油三酯浓度升高与不良临床结果的风险

2022-06-22 从医路漫漫 MedSci原创

血浆中的甘油三酯由乳糜粒和极低密度脂蛋白携带,统称为富含甘油三酯的脂蛋白(TGRL)。

背景:严重高甘油三酯血症相关的风险仍然不完全清楚。出于几个原因,人们对理解这些风险重新产生了兴趣。首先,随着越来越多的人肥胖和糖尿病患者,高甘油三酯血症在全球范围内的发病率正在增加。第三,孟德尔随机化研究重新探讨了高甘油三酯血症和冠心病之间的关系,表明两者之间可能存在因果联系。

血浆中的甘油三酯由乳糜粒和极低密度脂蛋白携带,统称为富含甘油三酯的脂蛋白(TGRL)。高甘油三酯血症的严重程度从轻微到非常严重不等,但TGRL的成分和代谢存在差异。临床指南广泛提倡当甘油三酯浓度达到10 mmol/L时降低甘油三酯,以降低急性胰腺炎的风险,因为因果和机制联系被广泛接受。

对于心肌梗死(MI),因果关系远不确定,测量的甘油三酯浓度可能更多地代表风险的生物标记物,风险由较小的载脂蛋白B携带TGRL和较大TGRL的不完全脂解残留物介导。在任何一种情况下,仍然需要充分了解与临床测量的高甘油三酯血症相关的风险程度,以帮助临床决策和风险分层,特别是在浓度非常高的情况下,因为这些结果现在更普遍。

在这方面,在一般人群中存在高甘油三酯血症的观察数据的情况下,针对不同的终点,包括AP和MI研究大多检查了甘油三酯水平在1.7到10 mmol/L之间的轻度到中度升高的人。甘油三酯>10 mmol/L的较高范围大多是在对既往胰腺炎患者进行的较小规模研究中评估的,包括那些转诊至脂肪诊所的患者,并有相关的选择偏差[15]。相比之下,研究了普通人群中严重高甘油三酯血症的风险,仅限于评估那些甘油三酯浓度>5·6 mmol/L或>11.3 mmol/L的人,通常没有参考正常值或通过使用索赔数据或保险数据库缺乏外部有效性

目的:为了更清楚地了解与高甘油三酯血症相关的风险,尤其是普通人群中严重的高甘油三酯血症,我们报告了从<1.7 mmol/L到>20 mmol/L的一系列常规测量的甘油三酯值与多种临床相关事件结局风险之间的关系,包括急性胰腺炎(AP)、慢性胰腺炎(CP)、心肌梗死(MI)、新发糖尿病和全因死亡。我们使用具有代表性的人群来实现这一点,这些人群具有相关的初级保健、二级保健和死亡率记录,利用英国国民健康保险制度提供的全民医疗保险。

方法:我们利用1500万人的一级和二级护理的相关数据,在中位数6-7年的随访中,探讨甘油三酯浓度与急性胰腺炎、慢性胰腺炎、新发糖尿病、心肌梗死和全因死亡率之间的关系。

结果:1,530,411人(平均年龄56·6±15·6岁,女性51·4%)甘油三酯浓度适宜,中位数为1.3 mmol/L(IQR:0.9~1.9)。重度高甘油三酯血症3289例(0.21%),其中620例甘油三酯>20 mmol/L。在多因素分析中,甘油三酯>20 mmol/L与急性胰腺炎(危险比)13·55(95%可信区间9·15-20·06)、慢性胰腺炎(HR 25·19(14·91-42·55))、慢性胰腺炎(HR 25·19(14·91-42·55))相关。与≤1.7mmoL/L的参考类别相比,糖尿病的高风险(HR5.28(4.51-6.18))和全因死亡率(hr3.62(2.82-4.65))与心肌梗死有关,然而,只有在1.7mmoL/L至10mmoL/L的中度高甘油三酯血症中才能观察到与心肌梗死有关。我们发现了与年龄的风险交互作用,与>40岁相比,≤40岁的患者所有结果的风险更高,包括死亡率。

图1甘油三酯组和临床结果的Kaplan-Meier分析。5年内5种临床结果中每一种甘油三酯水平的绝对风险,以及面临风险的数字。

图2甘油三酯浓度与临床结果相关的危险比的森林图。模型包括年龄和性别调整以及完全多变量调整,包括年龄、性别、BMI、饮酒、糖尿病、吸烟、高血压、降脂药物处方、高密度脂蛋白、总胆固醇以及按全科医学分层。

图3甘油三酯组和AP按年龄组≤40岁和>40岁分层的Kaplan-Meier分析

图4甘油三酯浓度和临床结果的危险比,根据年龄和性别进行调整,并按降脂治疗处方进行分层[他汀类药物(n=241,801),未服用他汀类药物(n=1,288,640),贝特类药物(n=15,891),未服用贝特类药物(n=1,514,550),任何LLD(n=250,806),未服用LLD(n=1,279,635)]

结论:我们强调了严重高甘油三酯血症与急性和慢性胰腺炎、新发糖尿病和死亡率之间的指数关系,特别是在年轻人,但对于只有中度高甘油三酯血症才有风险的心肌梗死来说,这并不是指数关系。

原文出处:Patel RS,  Pasea L,  Soran H, et al.Elevated plasma triglyceride concentration and risk of adverse clinical outcomes in 1.5 million people: a CALIBER linked electronic health record study.Cardiovasc Diabetol 2022 Jun 09;21(1)

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    2023-05-05 docwu2019
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    2022-10-21 quxin068
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1,高血脂分为高胆固醇血症与高甘油三酯血症等类型。虽然胆固醇更重要,但非专业人士关心最多的还是甘油三酯。本文重点说说饮食与甘油三酯增高的问题。

Diabetologia:中科院上海营养健康所:中老年人应注意这一指标,或影响糖尿病发病

近几十年来,我国居民的肥胖、代谢综合征及糖尿病等心血管代谢性疾病的患病率快速攀升,威胁居民健康。

血脂检查单中不起眼的它,竟与早期、晚期、总体前列腺癌发生风险升高都扯上关系?

PLOS Medicine:脂蛋白A和其他脂质与前列腺癌风险的关系:一项多变量孟德尔随机化研究

Cardiovasc Diabetol:累积甘油三酯-葡萄糖指数越高,心血管疾病风险越大!

发生心血管疾病的风险随着累积TyG指数的增加而升高

JCEM:血浆甘油三酯和白细胞介素6水平与体重反弹和脂肪量增加有关

这些结果提示TG和IL6通过不同的机制与体重反弹相关,HOMA-IR和脂肪细胞体积可能通过血浆TG水平的变化与体重反弹之间间接相关。