JACC发布高甘油三酯血症患者降低ASCVD风险的临床指南

2021-07-29 k.k MedSci原创

在患者使用降脂药物之前和期间,生活方式的干预,包括坚持心脏健康的饮食、定期体育锻炼、避免烟草制品、限制饮酒和保持健康体重,仍然是降低ASCVD风险的重要组成部分

Writing Committee et al.2021 ACC Expert Consensus Decision Pathway on the Management of ASCVD Risk Reduction in Patients With Persistent Hypertriglyceridemia: A Report of the American College of Cardiology Solution Set Oversight Committee.JACC. DOI: 10.1016/j.jacc.2021.06.011

对于动脉硬化性心血管疾病(ASCVD)的二级预防,2018年AHA/ACC/multisociety胆固醇指南引入了 "超高危的ASCVD群体 "的概念。二级ASCVD患者复发ASCVD事件的风险最大,因此,在他汀类药物治疗的基础上增加非他汀类药物治疗进一步降低LDL-C,可使得复发风险最大程度降低。

尽管使用了他汀类药物治疗,但甘油三酯升高的患者的ASCVD事件发生率仍然很高。流行病学和孟德尔随机化研究也指出,由于残余胆固醇颗粒的升高,甘油三酯的升高在动脉粥样硬化的症状中具有因果关系。甘油三酯的升高与残余胆固醇的增加有关。2018年AHA/ACC/multisociety胆固醇指南建议:将甘油三酯升高作为初级ASCVD预防的 "风险预警因素"。该指南建议将优化饮食和生活方式作为第一步,并考虑对有中度高甘油三酯血症和10年ASCVD风险升高的人进行他汀药物治疗。对于那些甘油三酯严重升高的患者(甘油三酯≥500mg/dL ,尤其是甘油三酯水平≥1000mg/dL 的患者),建议将降低甘油三酯作为一个治疗选择,以减少可能患胰腺炎的风险。

REDUCE-IT试验指的是减少心血管事件与Vascepa药物干预试验,包括ASCVD或糖尿病患者、甘油三酯升高的患者。在这项试验中,在他汀类药物治疗的基础上增加大剂量的Vascepa,使得ASCVD事件和心血管死亡风险降低。REDUCE-IT的结果已被纳入最近的指南。Vascepa获得FDA批准,用于降低特定患者群体的ASCVD风险。而关于omega-3脂肪酸制剂的试验结果随后发表,包括STRENGTH、OMEMI和VITAL试验,尽管只有REDUCE-IT试验显示了心血管益处。

而生活方式干预是管理高甘油三酯血症患者的一线疗法。高甘油三酯血症的原因往往是多因素的,应针对生活方式进行个体化治疗。指南建议,对于≥20岁的中度高甘油三酯血症的成年人,临床医生应首先干预生活方式,包括超重/肥胖、饮食质量差、久坐不动、饮酒。

根据2013年AHA/ACC/TOS成人超重和肥胖管理指南建议,持续减重3%~5%会带来健康益处。对于甘油三酯升高的患者,减肥被认为是降低甘油三酯最有效的干预方式;总体而言,体重减少5%~10%与甘油三酯减少20%有关。生活方式干预所减得体重与甘油三酯的降低之间存在着剂量反应关系。甘油三酯因体重减轻而降低至少50%~70%;但是也要视不同情况而定,一些病人只需减轻几公斤的体重就能明显降低甘油三酯,而其他病人尽管体重明显减轻,但甘油三酯降低的反应却很小。

总得来说,与低脂肪、高碳水化合物的饮食相比,高脂肪、低碳水化合物的饮食与甘油三酯的减少有关。所有限制碳水化合物的饮食都会导致体重显着减轻,极低碳水化合物饮食,甘油三酯降低幅度最大。也有证据表明高蛋白饮食与体重减轻得更多和甘油三酯的减少有关。此外,间歇性禁食的甘油三酯降低与体重减轻成正比。

在患者使用降脂药物之前和期间,生活方式的干预,包括坚持心脏健康的饮食、定期体育锻炼、避免烟草制品、限制饮酒和保持健康体重,仍然是降低ASCVD风险的重要组成部分。指南共识还为临床医生和患者提供了使用他汀类药物和非他汀类药物疗法的建议,以降低ASCVD、糖尿病、严重高甘油三酯血症风险。指南共识还建议营养师为高甘油三酯血症患者提供服务,以便他们得到个性化的营养指导。

原文出处:

Writing Committee et al.2021 ACC Expert Consensus Decision Pathway on the Management of ASCVD Risk Reduction in Patients With Persistent Hypertriglyceridemia: A Report of the American College of Cardiology Solution Set Oversight Committee.JACC. DOI: 10.1016/j.jacc.2021.06.011

 

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    2022-06-25 hbwxf
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    2022-02-15 quxin068
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    2021-07-31 doctorzheng
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