ACS降脂治疗高级班

急性冠脉综合症的降脂治疗Lipid-lowering treatment of acute coronary syndrome,北京市昌平中医医院：张碎虎,Contents,ACS病理基础,ACS病理基础,ACS斑块特征,大脂池（脂质核心占40%）大量炎性细胞浸润易损性（vulnerability） 血中血脂异常增高 内皮细胞功能损伤 局部炎症 血液动力学异常,李娇娇.心血管病防治知识(下半月),2013,12:150-153,ACS与血脂状态,有报道ACS患者应激状态下，血脂浓度有较大波动。AMI发生24h后，TC、LDL-C、HDL-C、apoA1和apoB均有明显下降，TG却增加。45d后变化最为明显，23个月后可回到基线状态。此时LDL和HDL颗粒性质发生了变化。作者认为，对于ACS患者，无论基线血脂浓度如何，都需要积极地应用他汀类药物进行强化降脂治疗。,赵水平.中华心血管病杂志,2013,41(7):542-543,ACS血脂状态,有人对59例ACS患者急性期24h内的血脂6项指标（TC、TG、HDL-C、LDL-C和ApoB、apoA1）与47例健康人的水平进行了比较,结果,结论：TC、TG、LDL-C、ApoB水平升高和HDL-C、ApoA1水平降低可能是ACS发病的危险因素，血脂6项指标联合检测有助于预测ACS的发生并监控病情的变化。,丁玲新等. 海南医学院学报,2011,11:1476-1478,ACS与血脂状态,另一篇报道：经冠脉造影诊断为CHD的367例患者，其中男性261例，女性106例，年龄2989(59.511.0)岁。268例ACS患者，99例非ACS患者作为对照，对两组患者的Lp(a)、HDL-C、ApoAl、TC、TG、LDL-C以及ApoB水平进行观察。,结果,结论,Lp(a)、HDL-C和ApoAl的水平在ACS患者和对照组患者中差异有统计学意义，提示我们在重视降低患者的TC,TG和LDL-C水平的同时，也应该关注HDL-C, ApoA1和Lp(a)水平的影响,曲环.中国心血管病研究,2008,6(6):410-412,ACS与血脂状态,另一项研究纳入333例ACS患者，男性232例（69.7%），女性101例（30.3%），年龄6210.63岁。其中UA257例（77.2%），NSTEMI50例，STEMI26例（7.8%），在发病期对患者血浆血脂浓度进行检测。,结果,结论,1.在ACS患者中，血脂异常较为常见2.大于50%是HDL-C1.0mmol/L,孙斌.郑州大学,2010年,学位论文,周亚玲.检验医学与临床,2014,z2:278-279,Effectsofatorvastatinonearlyrecurrent ischemic events in acute coronary syndromes: the MIRACL study: a randomized controlled trial.,A randomized, double-blind trial 1997.5 to 1999.9follow-up 16 weeks 122 clinical centers in Europe, NorthAmerica, South Africa, and Australasia.,A total of 3086 adults aged 18 years or older with unstable angina or non-Q-wave acute myocardial infarction.To determine whether treatment withatorvastatin 80 mg/d atorvastatin, initiated 24 to 96 hours after an acute coronary syndrome,Primary end point :death, nonfatal acute myocardial infarction, cardiac arrest with resuscitation, or recurrent symptomatic myocardial ischemia with objective evidence and requiring emergency rehospitalization.,Rulst,Conclusion,For patients with acute coronary syndrome, lipid-lowering therapy with atorvastatin, 80 mg/d, reduces recurrent ischemic events in the first 16 weeks, mostly recurrent symptomatic ischemia requiring rehospitalization.,Schwartz GG，et al. JAMA.2001Apr 4;285(13):1711-8.,Early Intensive vs a Delayed Conservative Simvastatin Strategy in Patients With Acute Coronary Syndromes Phase Z of the A to Z Trial,JAMA.2004;292(11):1307-1316. doi:10.1001/jama.292.11.1307.,A to Z(the Aggrastat to Zocor）,Time:December 29, 1999, and January 6, 2003Design:patients(n = 2265) with ACS receiving 40 mg/d of simvastatin for 1 month followed by 80 mg/d patients(n = 2232) with ACS patients receiving placebo for 4 months followed by 20 mg/d of simvastatin,Follow-up : 6 24months.The primary end point: Cardiovascular death Nonfatal myocardial infarction Readmission for ACS Stroke,simvastatin,Among patients with ACS, the early initiation of an aggressive simvastatin regimen resulted in a favorable trend toward reduction of major cardiovascular events.,Conclusions,ARMYDA Trial,Pasceri V, et alCirculation 2004;110:674-8,Atorvastatin for Reduction of Myocardial Damage During Angioplasty,153 patients scheduled for elective PCI irrespective of baseline lipid levelsRandomized, double-blind,Atorvastatin40 mg/d n=76,Placebo n=77,End Points,The primary end point ：occurrence of myocardial infarction（CK-MB 2 times ）Secondary end points ：other markers of myocardial injury（CK-MB, troponin I and myoglobin）upper normal limitsmean peak values of CK-MB, troponin I and myoglobin after interventionoccuring adverse cardiac events (death, myocardial infarction, or need for unplanned revascularization) Within a month,ARMYDA Trial,Primary endpoint of post-procedure MI (CKMB2x ULN) in atorvastatin group vs placebo (Figure) Presence of markers 1x ULN also in atorvastatin arm: CKMB 12% vs 35%, p=0.001; troponin I 20% vs 48% p=0.0004; myoglobin 22% vs 51%, p=0.0005,Circulation 2004;110:674-8,Post-procedure MI(2x ULN)p = 0.025,ARMYDA Trial,Circulation 2004;110:674-8,Peak values of CK-MB, troponin I, and myoglobin in statin vs placebo group. Data are meanSEM.,pretreatment with atorvastatin significantly reduced risk of periprocedural myocardial infarction (OR 0.19, 95% CI 0.05 to 0.57). Use of -blockers, glycoprotein IIb/IIIa inhibitors, or ACE inhibitors was not associated with risk reduction.,ARMYDA Trial,Among patients undergoing elective PCI, pre-treatment with atorvastatin was associated with a reduction in markers of myocardial injury post-procedureMechanism may be related to anti-inflammatory effect of statins,国内研究,68例血脂正常ACS患者被随机分为常规治疗组（34例，仅常规治疗），和辛伐他汀组（34例，常规治疗基础上加用辛伐他汀20mg/d），疗程6个月。于治疗前、后8周检测血浆BNP、hsCRP水平。所有患者每3个月随访一次，平均随访观察6个月，以住院或观察期间的心血管事件为终点。,结论,血脂正常的ACS患者，早期应用辛伐他汀干预可以显著降低血浆BNP、hs-CRP水平，减轻炎症反应，稳定动脉粥样硬化斑块减少心血管管事件发生。,翁根龙.心血管康复医学杂志，2012，21(1):70-72,国内研究,52例ACS患者随机分成3组，A组（常规治疗）；B组：辛伐他汀20 mg/ d，C组：辛伐他汀40mg/d，随访观察3组患者首次入院后1个月和1年的终点事件发生率(死亡、再发心绞痛或心肌梗死、再入