冠心病二级预防降脂-地位和策略

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1、冠心病二级预防降脂—地位和策略动脉粥样硬化+心肌缺血/坏死=冠心病进行性狭窄血管痉挛斑块破裂,出血,血栓缺血/坏死心肌缺血/坏死性事件DivinagraciaRA,1999冠心病防治总过程上游:冠状动脉粥样硬化防止病变发生或进展中游：狭窄、痉挛、血栓形成缓解症状或防止事件中游：心肌缺血、缺氧下游:冠心病(心绞痛、AMI、猝死）防范与减轻事件后果下游：AMI复发心衰防治复发或延缓病情一、防止病变发生或进展AS是一多危险因素所致的慢性、进展性病变四大主要危险因素：吸烟、血脂异常、高血压和糖尿病血脂异常（尤其是胆固醇

2、升高）是最为重要的危险因素基础与临床研究证实：防止AS，降脂最重要-20-265-33-22-31*-35-30-25-20-15-10-50510ShepherdJetal.NEnglJMed.1995;333:1301-1307.*P<0.0005.†P=0.042.‡P=0.051.Subjects:6,595menAgerange:45-64yrMeanbaselineTC:272mg/dLMeanbaselineLDL-C:192mg/dLDuration:5yrIntervention:Pravas

3、tatin40mg/day†TCLDL-CHDL-CNonfatalMI/CHDdeathCHDdeathAll-causemortalityWOSCOPS:EffectsofLipidLoweringonCoronaryEventsinPrimaryPreventionTrialinMen‡%+AFCAPS/TexCAPS:EffectsofLDL-CLoweringinPatientsWithAverageCholesterolLevels%TCLDL-CHDL-CMICHDUARVSubjects:6,

4、60585%men,45-73yr15%women,55-73yrBaselinelipids:TC:221mg/dLLDL-C:150mg/dLHDL-C:men,36mg/dLwomen,40mg/dLIntervention:Lovastatin20-40mg/dayC=coronaryeventsdefinedasfatal/nonfatalmyocardialinfarction,suddendeath,andunstableangina;MI=fatal/nonfatalmyocardialinf

5、arction;UA=unstableangina;RV=revascularizations.DownsJRetal.JAMA.1998;279:1615-1622.P<0.001P=0.002P=0.02P=0.001辛伐他汀:既往的血管事件危险性比值和95%可信区间他汀安慰剂基线特征(10,269)(10,267)他汀更好他汀更差STATINworse心梗史1,0071,255其他冠心病(非心梗)452597无冠心病史心血管疾病182215外周血管疾病332427糖尿病279369所有患者2,0422,6

6、06(19.9%)(25.4%)降低24%，标准误2.6(2P<0.00001)0.40.60.81.01.21.4心脏保护研究(HPS)36%ASCOT主要终点：致死性冠心病和非致死性心肌梗死HR=0.64(0.50-0.83)阿托伐他汀10mg事件数目100安慰剂事件数目154p=0.0005SeverPS,DahlöfB,PoulterN,WedelH,etal,fortheASCOTInvestigators.Lancet.2003;361:1149-58二、缓解症状或防止事件（1）（冠心病的基础治疗措

7、施）解除狭窄斑块消退：他汀类；钙拮抗剂；ACEI？稳定斑块：他汀类；ACEI？机械作用：冠脉介入治疗缓解痉挛直接解痉：硝酸酯类；钙拮抗剂间接解痉：他汀类（改善冠脉内皮功能）斑块消退：他汀类定量冠脉造影试验冠脉内超声检查颈动脉斑块和内中膜厚度检测LipidLoweringandPlaqueRegression:MonotherapyStudiesNHLBIIID+R31—33STARSD+R367.7(<0.01)89HeidelbergD+E84.0(0.05)-27*CCAITD+L291.2(

8、0.039)—MARSD+L380.6—BECAITD+F32.5577LCASD+Fl242.0(0.043)33Post-CABGD+L145.4(0.001)—*A-27%reductionmeansa27%increase(NS).D=diet;R=resin;E=exerciseprogram;F=fibrate-typedrug;Fl=fluvastati