Clin Pharmacol Ther:他汀一级预防再获力证 不同冠心病风险人群均有获益

2018-12-18 常路 环球医学

新的血脂异常管理指南推荐个体化预防措施,以降低心血管事件发生率,并关注两个受益群体:首先是进行二级预防的患者,如糖尿病患者、合并一种或多种心血管危险因素(血脂异常、高血压或吸烟)的患者、或慢性肾病患者;其次是10年心血管风险评估的个体。这些指南降低了10年心血管风险评估阈值,以降低心血管事件的发生率。

新的血脂异常管理指南推荐个体化预防措施,以降低血管事件发生率,并关注两个受益群体:首先是进行二级预防的患者,如糖尿病患者、合并一种或多种血管危险因素(血脂异常、高血压或吸烟)的患者、或慢性肾病患者;其次是10年心血管风险评估的个体。这些指南降低了10年心血管风险评估阈值,以降低心血管事件的发生率。

对于一级预防,欧洲指南推荐,10年发生致死性心血管风险≥5%、低风险(<5%)但低密度脂蛋白(LDL)胆固醇水平在2.6~4 mmol / L的个体,应开始治疗。美国指南则建议,40~75岁的个体如10年风险评分≥7.5%,要进行治疗。英国国家健康与临床卓越研究所则建议,10%风险人群均应进行他汀一级预防。这些推荐基于既往的荟萃分析和最新的临床研究结果,这些结果表明他汀在高和中度心血管风险人群中疗效相似。

但由于以下原因,指南最新推荐的这些阈值备受争议:首先,符合终生他汀治疗的人群将大幅增加。其次,关注的是相对而非绝对风险的降低。最后,指南所依据临床试验的随机化未考虑基线的心血管风险。

因经常要排除特定群体(他汀不耐受或依从性不佳、糖尿病、女性、年轻人),临床试验的参与者可能无法代表普通人群。2018年10月,发表在《Clin Pharmacol Ther》的一项基于人群的队列研究,再次分析了他汀在不同冠心病风险水平的普通人群中的有效性。

将既往无心血管疾病的人群(35~74岁)纳入到研究中,并根据10年冠心病风险(<5%、5~7.4%、7.5%~9.9%和10%~19.9%)进行分层。根据药物持有率对新使用者进行分类。主要结局指标为动脉粥样硬化性心血管疾病(ASCVD)(心梗和缺血性卒中)。

在依从良好的患者中(药物持有率≥70%),他汀治疗可降低各冠状动脉风险范围人群的ASCVD风险(16%~30%)。

风险<5%和5~7.4%,5年需治数(NNT)分别为470和204;风险为7.5%~9.9%和10%~19.9%,则分别为75和62。

因此,作者认为,在10年冠心病风险较高(10%~19.9%)患者中,仍应优先考虑他汀治疗。多数中等风险患者可从他汀治疗中获益,但是鉴于需治数较高,治疗决策应该关注净获益、安全性和患者偏好。

当前,心脑血管疾病预防战线正不断前移,从二级预防前移至一级预防。目前,他汀类药物在心脑血管疾病一级/初级预防中的证据也在日益增加,地位在不断提升,但临床医生使用他汀时也要考虑药物副作用、费用、患者偏好等,客观且灵活应用。

原始出处:

Garcia-Gil M, Comas-Cufí M, Blanch J, et al. Effectiveness of Statins as Primary Prevention in People With Different Cardiovascular Risk: A Population-Based Cohort Study. Clin Pharmacol Ther. 2018 Oct;104(4):719-732. doi: 10.1002/cpt.954. Epub 2018 Feb 2.

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    2019-01-31 yb6560
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