血脂治疗与临床指南

JNC7:ClassificationandManagementofBloodPressureforAdults*,*TreatmentdeterminedbyhighestBPcategoryTreatpatientswithchronickidneydiseaseordiabetestoBPgoalof130/80mmHgInitialcombinedtherapyshouldbeusedcautiouslyinthoseatriskfororthostatichypotensionSBP=systolicbloodpressure;DBP=diastolicbloodpressure;ACEI=angiotensin-convertingenzymeinhibitor;ARB=angiotensinreceptorblocker;BB=b-blocker;CCB=calciumchannelblockerJNC7.May2003.NIHpublication03-5233.,JNC7:TreatmentAlgorithmforHypertension,SBP=systolicbloodpressure;DBP=diastolicbloodpressure;ACEI=angiotensin-convertingenzymeinhibitor;ARB=angiotensinreceptorblocker;BB=b-blocker;CCB=calciumchannelblockerJNC7.May2003.NIHpublication03-5233.,Lifestylemodifications,ATPIII:NewFeaturesofGuidelinesFocusonMultipleRiskFactors,PersonswithdiabeteswithoutCHDraisedtolevelofCHDriskequivalentFramingham10-yearabsoluteCHDriskprojectionsusedtoidentifycertainpatientswith2riskfactorsformoreintensivetreatmentPersonswithmultiplemetabolicriskfactors(themetabolicsyndrome)identifiedascandidatesforintensifiedtherapeuticlifestylechanges(TLC),ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,ATPIII:NewFeaturesofGuidelinesApplyingtheRecommendations,Completefastinglipoproteinprofile(TC,LDL-C,HDL-C,TG)recommendedaspreferredinitialtestUseofplantstanols/sterolsandviscousfiberencouragedastherapeuticdietaryoptionstoenhanceLDL-CloweringStrategiespresentedtoimproveadherencetotherapeuticlifestylechanges(TLC),drugtherapiesIntensiveTLCrecommendedforpersonswiththemetabolicsyndromeNonHDL-C(TCminusHDL-C)goalrecommendedassecondarytargetforpersonswithhighTGlevels(200mg/dL),ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,ATPIII:FeaturesSharedwithATPII,LDL-CloweringremainsprimarygoaloftherapyHighLDL-C(160mg/dL)consideredtargetforLDL-CloweringdrugtherapyIntensiveLDL-CloweringemphasizedinpersonswithCHD3riskcategoriesfordifferentLDL-CgoalsandintensitiesofLDL-CloweringtherapySubpopulations(otherthanmiddle-agedmen)identifiedfordetectionofhighLDL-C,clinicalintervention:youngadults;postmenopausalwomen;olderpersonsWeightloss,physicalactivityemphasizedtoreduceriskinpersonswithelevatedLDL-C,ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,ATPIII:LDL-C,HDL-C,TCClassification,ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,ATPIII:MajorCHDRiskFactorsOtherThanLDL-C,CigarettesmokingHypertension:BP140/90mmHgoronantihypertensivemedicationLowHDL-C:40mg/dL*FamilyhistoryofprematureCHD(1st-degreerelative):malerelativeage55yearsfemalerelativeage65yearsAgemale45yearsfemale55years,*HDL-C60mg/dLisanegativeriskfactorandnegatesoneotherriskfactor.,ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,ATPIII:AdditionalCHDRiskFactors,ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,Life-habitriskfactors:targetsforintervention;notusedtosetlowerLDL-CgoalobesityphysicalinactivityatherogenicdietEmergingriskfactors:canhelpguideintensityofrisk-reductiontherapy;donotcategoricallyalterLDL-Cgoalslipoprotein(a)homocysteineimpairedfastingglucoseprothromboticandsubclinicalatheroscleroticproinflammatoryfactorsdisease,ATPIII:AssessmentofRisk,ForpersonswithoutknownCHD,otherformsofatheroscleroticdisease,ordiabetes:Countthenumberofriskfactors.UseFraminghamscoringforpersonswith2riskfactors*todeterminetheabsolute10-yearCHDrisk.,*Forpersonswith01riskfactor,Framinghamcalculationsarenotnecessary.,ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,ATPIII:RiskCategories,LDL-CGoals,*Almostallpeoplewith01riskfactorhavea10-yearrisk20%per10years),Otherclinicalformsofatheroscleroticdiseaseperipheralarterialdisease(PAD)abdominalaorticaneurysm(AAA)carotidarterydiseaseDiabetesMultipleriskfactors*,AdultTreatmentPanelIII.NIHpublication01-3095.,*DeterminedwithATPIIIFraminghamriskscoring.,ATPIII:LDL-CTreatmentCutpointsforTherapy,*TherapeuticlifestylechangesSomeauthoritiesuseLDL-CloweringdrugsifTLCdoesnotachieveLDL-C100mg/dL;othersusedrugstomodifyHDL-CandTG.,ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,ATPIII:NutritionalComponentsoftheTLCDiet,ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,*TransfattyacidsalsoraiseLDL-Candshouldbekeptatalowintake.Note:Regardingtotalcalories,balanceenergyintakeandexpendituretomaintaindesirablebodyweight.,ATPIII:AdditionalDietaryOptionsforLDL-CLowering,Viscous(soluble)fiber:510g/dayeg,oats,guar,pectin,psylliumPlantstanols/sterols:2g/dayavailableincommercialmargarineswithintakeoffruitsandvegetablesSoyprotein:2540g/daywhenreplacinganimalfoodproducts,AdultTreatmentPanelIII.NIHpublication01-3095.,ATPIII:ManagementofVeryHighLDL-C,LDL-C190mg/dLusuallytracedtogeneticformsofhypercholesterolemiaRecommendedactions:earlydetectioninyoungadultsthroughcholesterolscreeningtopreventprematureCHDfamilycholesteroltestingtoidentifyaffectedrelativescombinationdrugtherapyusuallyrequiredtoachievetargetLDL-Clevels,ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,ATPIII:ManagementofLowHDL-C,LowHDL-C:40mg/dL(nospecificgoaldefinedforraisingHDL-C)Targetsoftherapy:allpersonswithlowHDL-C:achieveLDL-Cgoal;thenweight,physicalactivity(ifmetabolicsyndromeispresent)thosewithTG200499mg/dL:achievenonHDL-Cgoal*assecondaryprioritythosewithTG65yearsofage(prematureCHD65yearsofageattributedtomultipleriskfactors,metabolicsyndrome)HRTuseforCHDriskreductionnotsupportedbyclinicaltrialresults;cholesterol-loweringtherapy(statins)hasbeenshowntoreduceCHDriskandisrecommendedMiddle-AgedMen(3565yearsofage)highprevalenceofmajorriskfactors;predisposedtoabdominalobesity,metabolicsyndromeintensiveLDL-CloweringrecommendedforthoseatrelativelyhighCHDrisk,ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,ATPIII:SpecialPopulationsOlderAdults,YoungerAdults,OlderAdults(men65yearsofage;women75yearsofage)first-linetherapy:TLC;forhigherrisk,considerLDL-CloweringdrugYoungerAdults(men2035yearsofage;women2045yearsofage)risk-factoridentificationimportantforlong-termpreventionLDL-C130mg/dL:emphasizeTLCmenwithLDL-C160189mg/dLwhosmoke:considerLDL-CloweringdrugallyoungadultswithLDL-C190mg/dLwarrantdrugtherapy,ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,ATPIII:ImprovingAdherenceFocusonthePatient,Foroptimumeffectiveness,physiciansshouldemploy2oftheseapproachesforeachpatient:KeepmedicationregimenssimpleMakeinstructionsveryexplicitSuggestuseofpromptsUtilizesystemstomaintainpatientcontactEncouragesupportfromfamily,friendsReinforce,rewardadherenceIncreasevisitsforthosewhocannotreachtreatmentgoalMakecaremoreconvenient,accessibleEncourageself-monitoring,ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,ATPIII:ImprovingAdherenceFocusonthePhysician,DeliverySystem,Forthephysician,medicaloffice:UsepromptstohighlightlipidmanagementIdentifyanin-officepatientadvocateInvolvepatientstopromptpreventivecareUsefeedbacktomodifyfuturecareForthehealthdeliverysystem:ProvidelipidmanagementthroughalipidclinicUtilizecasemanagementbynursesImplementtelemedicine(phonefollow-up)proceduresInvolvepharmacistsincollaborativecareDevelopin-hospitalcriticalcarepathways,ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,Note:RiskestimateswerederivedfromtheexperienceoftheFraminghamHeartStudy,apredominantlyCaucasianpopulationinMassachusetts,USA.ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,AssessingCHDRiskinMen,Step2:TotalCholesterol,TCPointsatPointsatPointsatPointsatPointsat(mg/dL)Age20-39Age40-49Age50-59Age60-69Age70-7916000000160-19943210200-23975310240-27996421280118531,PointTotal10-YearRiskPointTotal10-YearRisk01%118%01%1210%11%1312%21%1416%31%1520%41%1625%52%1730%62%73%84%95%106%,Step7:CHDRisk,ATPIIIFraminghamRiskScoring,PointTotal10-YearRiskPointTotal10-YearRisk91%2011%91%2114%101%2217%111%2322%121%2427%132%2530%142%153%164%175%186%198%,AssessingCHDRiskinWomen,Note:RiskestimateswerederivedfromtheexperienceoftheFraminghamHeartStudy,apredominantlyCaucasianpopulationinMassachusetts,USA.ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,TCPointsatPointsatPointsatPointsatPointsat(mg/dL)Age20-39Age40-49Age50-59Age60-69Age70-7916000000160-19943211200-23986421240-2791185322801310742,Step7:CHDRisk,Step2:TotalCholesterol,ATPIIIFraminghamRiskScoring,Step1:Age,ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,ATPIIIFraminghamRiskScoring,Step2:TotalCholesterol,Note:TCandHDL-Cvaluesshouldbetheaverageofatleasttwofastinglipoproteinmeasurements.ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,Men,TCPointsatPointsatPointsatPointsatPointsat(mg/dL)Age20-39Age40-49Age50-59Age60-69Age70-7916000000160-19943210200-23975310240-27996421280118531,Women,TCPointsatPointsatPointsatPointsatPointsat(mg/dL)Age20-39Age40-49Age50-59Age60-69Age70-7916000000160-19943211200-23986421240-2791185322801310742,ATPIIIFraminghamRiskScoring,Step3:HDL-Cholesterol,Note:HDL-CandTCvaluesshouldbetheaverageofatleasttwofastinglipoproteinmeasurements.ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,Men,Women,ATPIIIFraminghamRiskScoring,Step4:SystolicBloodPressure,Note:TheaverageofseveralBPmeasurementsisneededforanaccuratemeasurementofbaselineBP.Ifanindividualisonantihypertensivetreatment,extrapointsareadded.ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,ATPIIIFraminghamRiskScoring,Step5:SmokingStatus,Note:Anycigarettesmokinginthepastmonth.ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,ATPIIIFraminghamRiskScoring,Step6:AddingUpthePoints(SumFromSteps15),ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,ATPIIIFraminghamRiskScoring,Step7:CHDRiskforMen,Note:Determinethe10-yearabsoluteriskforhardCHD(MIandcoronarydeath)frompointtotal.ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,ATPIIIFraminghamRiskScoring,Step7:CHDRiskforWomen,Note:Determinethe10-yearabsoluteriskforhardCHD(MIandcoronarydeath)frompointtotal.ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.,ATPIIIFraminghamRiskScoring,ATPII,ATPIII,Studypopulation(millions),ATPIIIvsATPII:IncreasesinTreatment-EligiblePrimary-PreventionPatients,DatafromFedderDOetal.Circulation.2002;105:152-156.,122%,157%,201%,131%,7.7,7.4,3.9,4.2,19.9,16.4,11.6,9.7,0,5,10,15,20,25,Males(overall),Females(overall),10mg/L,testshouldberepeated,patientexaminedforsourcesofinfectionorinflammationRelativeriskcategoriesforhs-CRPlevels:low3.0mg/L,AHA/CDCPanel:Recommendationsforhs-CRPLaboratoryTesting,PearsonTAetal.Circulation.2003;107:499-511.,2004PPS,0,20,40,60,80,100,LipidLowering,LDL-C,BPControl,%,LaBreshKAetal.ArchInternMed.2004;164:203-209.,*BasedonAHA/ACCsecondary-preventionguidelines.Lipidloweringindicatesuseoflipid-loweringagentsatdischarge;low-densitylipoproteincholesterol(LDL-C)leveldeterminedinhospital;bloodpressure(BP)140/90mmHgattimeofdischarge.P0.05;significancebasedonnonoverlapping95%confidenceintervalscomparedwithbaseline.,N=1,738,AHAGetWiththeGuidelines:AdherencetoTreatmentMeasures*,2004PPS,AHAEvidence-BasedGuidelinesforCVDPreventioninWomen,KeyStrategiesforClinicalPracticeAssess,stratifybasedonrisk,treataccordingtoriskcategoryUrgelifestylechanges30minutesmoderate-intensityphysicalactivitydailySmokingcessationWeightmaintenance/reductionHeart-healthydietEncourageoptimalBP50mg/dLTG150mg/dLNonHDL-C20%)NotRecommendedinClinicalPractice(ClassIII)MenopausalhormonetherapytopreventCVDRoutineuseofaspirininlower-riskwomen(trialsongoing);discretionaryinintermediate-riskwomenAntioxidantvitaminsupplementstopreventCVD(trialsongoing),ExpertPanel/WritingGroup.Circulation.2004;109:672-693.,ClassIIa:Evaluate/treatfordepression,ClassIIb:Omega3fatty-acidsupplementationFolicacidsupplementation,ClassI:SmokingcessationPhysicalactivity/cardiacrehabilitationDiettx;weightmaintenance/reductionBP,lipidcontrol(statintx)Aspirin,-blockertxACEinhibitortx(ARBsifcontraindicated)Glycemiccontrolindiabetes,StatinAdvisory:DefinitionsofMuscleToxicity,Myopathyageneraltermreferringtoanydiseaseofmuscles;myopathiescanbeacquiredorinheritedandcanoccuratbirthorlaterinlifeMyalgiamuscleacheorweaknesswithoutcreatinekinase(CK)elevationMyositismusclesymptomswithincreasedCKlevelsRhabdomyolysismusclesymptomswithmarkedCKelevation(10 xtheupperlimitofnormalULN)andcreatinineelevation(usuallywithbrownurineandurinarymyoglobin),PasternakRCetal.JAmCollCardiol.2002;40:568-573.PasternakRCetal.Circulation.2002;106:1024-1028.,StatinAdvisory:MonitoringParameters,Follow-UpSchedule,ALT=alaninetransferase;AST=aspartatetransferase.,PasternakRCetal.JAmCollCardiol.2002;40:568-573.PasternakRCetal.Circulation.2002;106:1024-1028.,StatinAdvisory:ClinicalPrecautionsWhenPrescribingStatinTherapy,MyopathymorelikelytooccurathigherdosesDosesshouldnotexceedthoserequiredtoattainATPIIIgoalsAttentionshouldbepaidtofactorsthatmayincreaseriskformyopathy(seenextslide),PasternakRCetal.JAmCollCardiol.2002;40:568-573.PasternakRCetal.Circulation.2002;106:1024-1028.,StatinAdvisory:RiskFactorsforStatin-AssociatedMyopathy,Concomitantmedsorconsumptionof:FibratesNicotinicacid(rarely)CyclosporineAzoleantifungalsItraconazole,ketoconazoleMacrolideantibioticsErythromycin,clarithromycinHIVproteaseinhibitorsNefazodone(antidepressant)VerapamilAmiodaroneLargequantitiesofgrapefruitjuice(1qt/d)Alcoholabuse,Otherconsiderations:Advancedage(especially80yr;womenmorethanmen)Smallbodyframe,frailtyMultisystemdisease(eg,chronicrenalinsufficiency,especiallyduetodiabetes)MultiplemedicationsPerioperativeperiods,PasternakRCetal.JAmCollCardiol.2002;40:568-573.PasternakRCetal.Circulation.2002;106:1024-1028.,StatinAdvisory:Conclusions,Statinsreducetheincidenceofmajorcoronaryevents,coronaryprocedures,andstrokeinhigh-riskpatientsThispotentialisnotfullyrealizedduetounderuseinclinicalpracticeStatinsaresafeinthevastmajorityofpatientsStatinsshouldbeusedwithappropriatecaution,particularlyinselectedpatients,PasternakRCetal.JAmCollCardiol.2002;40:568-573.PasternakRCetal.Circulation.2002;106:1024-1028.,ADA:GlycemicControl,BP,andLipidTargetsinType2Diabetes,*Referencedtoanondiabeticrangeof4.0%6.0%usingaDCCT-basedassay.ATPIIIguidelinessuggestwhenTGis200mg/dL,usenonHDL-C(TCminusHDL-C);goalinpatientswithdiabetesis130mg/dL(LDL-Cgoal+30mg/dL).Forwomen,anHDL-Cgoal10mg/dLhighermaybeappropriate.DCCT=DiabetesControlandComplicationsTrial,ADA.DiabetesCare.2003;26(suppl1):S33-S50.,ADA:TreatmentDecisionsbyLDL-CLevels*inAdultsWithType2Diabetes,InitiationLDL-CInitiationLDL-CStatuslevelgoallevelgoal