高血脂症治疗之新趋势课件

高血脂症治療之新趨勢高血脂症治療之新趨勢 成大醫院 心臟內科 李貽恆 N N EnglEngl J Med. J Med. 1997;337:408416. 1997;337:408416. Importance of Cholesterol in Atherosclerosis Importance of Cholesterol in Atherosclerosis Prospective Cardiovascular Mnster Study CHD Risk According to LDL Cholesterol Incidence (per 1,000 in 6 years) LDL cholesterol 177 events, 4263 men aged 40-65 years 16 31 54 120 Taken from Lipid Metabolism Disorders and Coronary Heart Disease, G. Assmann, Editor, MMV Medizin Verlag, Munich 1993 195 5.0 (mg/dl) (mmol/L) Steps for Evaluation of Hypercholesterolemia National Cholesterol Education Program (NCEP): National Cholesterol Education Program (NCEP): The Third Report in Adult Treatment Panel (ATP III) The Third Report in Adult Treatment Panel (ATP III) Step 1 Determine Lipoprotein Levels lObtain complete lipoprotein profile (total cholesterol, LDL, HDL, triglyceride) after 9- to 12-hour fast lIn all adults aged 20 years or older, a fasting lipid profile should be obtained once every 5 years Step 2 Identify Presence of CHD or CHD Risk Equivalent lClinical Coronary heart disease (CHD) lSymptomatic carotid artery disease lPeripheral arterial disease lAbdominal aortic aneurysm l l DiabetesDiabetes Step 3 Determine Presence of Major Risk Factors lCigarette smoking lHypertension lLow HDL (100 to 130 risk equivalent 2+ risk factors130 to 160 0-1 risk factor160 to 190 NCEP ATP III LDL Cholesterol GoalsNCEP ATP III LDL Cholesterol Goals and Therapy Recommendationsand Therapy Recommendations *Authorities disagree on when to initiate drug therapy. This category refers to patients without clinically evident CHD, but who have a similar risk for CHD events (eg, patients with diabetes, multiple risk factors, or other forms of atherosclerotic disease, such as peripheral artery disease). NCEP ATP III guidelines. JAMA. 2001;285:2486-2497. Initiate therapeutic lifestyle changesGoal Initiate drug therapy* LDL cholesterol level (mg/dL) Current treatment guideline in TaiwanCurrent treatment guideline in Taiwan CHD or DMCHD or DM TC 200mg/dL or LDL-C 130mg/dL Goal TC 4 min w/o ischemia lAsymptomatic to mildly symptomatic (Class I-II angina) l1-2 vessel disease lTarget stenosis 50-90% lLDL 115 mg/dl lTG 925 events) Primary Endpoint: Death, MI, Documented UA requiring hospitalization, revascularization ( 30 days after randomization), or Stroke PROVE IT - TIMI 22 Study Design 2x2 Factorial: Gatifloxacin vs. placebo Double-blindDouble-blind Changes from Baseline in Median LDL-C Note: Changes in LDL-C may differ from prior trials: Note: Changes in LDL-C may differ from prior trials: 25% of patients on statins prior to ACS event 25% of patients on statins prior to ACS event ACS response lowers LDL-C from true baseline ACS response lowers LDL-C from true baseline LDL-C (mg/dL) 20 40 60 80 100 120 Rand. 30 Days 4 Mos.8 Mos.16 Mos.Final Pravastatin 40mg Atorvastatin 80mg 49% 49% 21%21% P0.001P0.001 Median LDL-C (Q1, Q3)Median LDL-C (Q1, Q3) 95 (79, 113)95 (79, 113) 62 (50, 79) 62 (50, 79) 24h All-Cause Death or Major CV Events All-Cause Death or Major CV Events in All Randomized Subjectsin All Randomized Subjects 0 0 3 3 18182121242427273030 6 6 9 9 12121515 % with Event Months of Follow-up Pravastatin 40mgPravastatin 40mg (26.3%)(26.3%) Atorvastatin 80mgAtorvastatin 80mg (22.4%)(22.4%) 16% RR16% RR (P = 0.005)(P = 0.005) 3030 2525 2020 1515 1010 5 5 0 0 Our findings indicate that patients recently hospitalized for an acute coronary syndrome benefit from early and continued lowering of LDL-C to levels substantially below current target levels. Cannon CP, Braunwald E, McCabe CH, et al. Cannon CP, Braunwald E, McCabe CH, et al. N Engl J MedN Engl J Med 2004;350:15 2004;350:15 Monitoring statin use lHeadache, dyspepsia lMuscle soreness, tenderness and pain Evaluate muscle symptoms and CK before starting therapy, at 6-12 wks after therapy and at each visit. lGOT, GPT Evaluate GOT/GPT initially, 12 weeks after therapy and annually or more frequently if necessary. JACC 2002;40:567 Current treatment guideline in TaiwanCurrent treatment guideline in Taiwan CHD or DMCHD or DM TC 200mg/dL or LDL-C 130mg/dL Goal TC 160mg/dL or LDL-C 100mg/dL 2+ Risk Factor:2+ Risk Factor: TC 200mg/dL or LDL-C 130mg/dL Goal TC 200mg/dL or LDL-C 130mg/dL 0-10-1+ + Risk Factor:Risk Factor: TC 240mg/dL or LDL-C 160mg/dL Goal TC 240mg/dL or LDL-C 160mg/dL Risk Factors: (adapted from BNHI lipid treatment guideline)Risk Factors: (adapted from BNHI lipid treatment guideline) HypertensionHypertension Family history of premature CHDFamily history of premature CHD Male Male 45 yrs 45 yrs Female Female 55 yrs or postmenopausal women without treating by ERT 55 yrs or postmenopausal women without treating by ERT SmokingSmoking Summary lWell control of hyperlipidemia can reduced CAD lLDL level is the first target to treat lHMGCoA reductase inhibitors are effective lipid- lowering drugs with clinical evidence lEarly administration of statin in acute coronary syndrome can reduce ischemic events Classification of Serum Triglycerides Normal 150 mg/dL Borderline high 150199 mg/dL High200499 mg/dL Very high 500 mg/dL ATP III Lipid and ATP III Lipid and Lipoprotein ClassificationLipoprotein Classification New Features of ATP III Non-HDL Chole