ACCAHA胆固醇新指南IAS血脂异常管理的全球建议解读课件

ACC/AHA胆固醇新指南、

IAS血脂异常管理的全球建议解读

ACC/AHA胆固醇新指南、

IAS血脂异常管理的全球建议解ACC/AHA胆固醇新指南要点完全依据RCT证据聚焦胆固醇---LDL-CACC/AHA胆固醇新指南要点完全依据RCT证据四个需他汀治疗人群ASCVDLDL-C>190mg/dlII型糖尿病40-75岁（LDL-C70-189mg/dl）10年ASCVD风险≥7.5%（LDL-C70-189mg/dl）四个需他汀治疗人群ASCVD三个他汀剂量强LDL-C↓≥50%阿托伐他汀80（40）；瑞舒伐他汀40,20中LDL-C↓30%-50%阿托伐他汀10（20），瑞舒伐他汀5，10；辛伐他汀20，40；普伐他汀40（80）；氟伐他汀80弱LDL-C↓<30%比中等强度剂量更小三个他汀剂量强LDL-C↓≥50%不同人群他汀剂量推荐ASCVDLDL-C>190mg/dlII型糖尿病（40-75岁）10年ASCVD风险≥7.5%大剂量中-大剂量不同人群他汀剂量推荐ASCVD大剂量中-大剂量两个不建议使用他汀人群心功能不全（心功能II-IV级）慢性肾功能不全两个不建议使用他汀人群心功能不全（心功能II-IV级）一个用他汀需谨慎人群年龄≥75岁一个用他汀需谨慎人群年龄≥75岁指南不适宜人群亚裔指南仅适用美国黑人白人指南不适宜人群亚裔设置警戒线LDL-C<40mg/dl设置警戒线LDL-C<40mg/dl不推荐他汀以外的调脂药物依折麦布贝特烟酸血脂康植物甾醇不推荐他汀以外的调脂药物依折麦布IAS建议Panel(15人）Chair:ScottM.Grundy美国Member：HidenoriArai日本 PhilipBarter澳大利亚IAS主席 ThomasP.Bersot美国 D.JohnBetteridge英国 RafaelCarmena西班牙 AdaCuevas智利 MichaelH.Davidson美国 JacquesGenest加拿大 Y.AnteroKesäniemi芬兰 ShaukatSadikot印度 RaulD.Santos巴西 AndreyV.Susekov俄罗斯 RodyG.Sy菲律宾 S.LaleTokgözoglu土耳其 GeraldF.Watts澳大利亚 DongZhao中国IAS建议Panel(15人）Chair:建议的证据基础流行病学研究遗传学研究临床试验（RCT）病理学研究药理学研究代谢研究较小规模临床试验临床试验的荟萃分析动物实验/基础研究建议的证据基础流行病学研究病理学研究RCT的局限性主要为药物试验，生活方式干预试验很少主要在欧美国家人群，其他人群较少入选标准/排除标准，研究对象的代表性局限大多数由制药企业赞助，主要为药物注册上市而非回答临床干预中的临床问题RCT的局限性主要为药物试验，生活方式干预试验很少动脉粥样硬化--生活方式病基于流行病学而非RCT完全依赖RCT的指南重视药物，忽略生活行为二级预防：药物重要一级预防：生活方式干预/改变不健康生活习惯优先动脉粥样硬化--生活方式病基于流行病学而非RCT坚持百年胆固醇学说不动摇血清胆固醇水平↑

→

CHD风险↑血清胆固醇水平低→

CHD风险低降低血清胆固醇→降低CHD风险-RCT流行病学坚持百年胆固醇学说不动摇血清胆固醇水平↑→CH坚持百年胆固醇学说不动摇致动脉粥样硬化脂蛋白LDL一定程度升高---动脉粥样硬化/ASCVD必要条件LDL占致动脉粥样硬化脂蛋白75%Cholesterol-enrichedremnants(富含甘油三酯脂蛋白,即VLDL）25%TG升高时起作用较大VLDL中致动脉粥样硬化的组分是胆固醇，不是TGLDL浸润动脉壁--启动/促进动脉粥样硬化坚持百年胆固醇学说不动摇致动脉粥样硬化脂蛋白LDL一定程度升LDL-C增高单一因素即可致ASCVD家族性高胆固醇血症（FH）（即使无任何其他危险因素）早发动脉粥样硬化和临床ASCVD

--BrownandGoldstein1976LDL-C增高单一因素即可致ASCVD家族性高胆固醇血症（FLDL水平低的人群即使存在其他危险因素（吸烟、高血压、HDL↓、糖尿病）无早发ASCVD---Grundy等1990LDL水平低的人群即使存在其他危险因素LDL升高是“源”其他危险因素是“流”LDL升高

到足以启动动脉粥样硬化程度其他危险因素促进加快动脉粥样硬化ASCVD预防必须聚焦LDL↓并保持终生低水平LDL升高是“源”其他危险因素是“流”LDL升高到足以ASCVD的危险因素MajorriskfactorsEmergingriskfactorsUnderlyingriskfactorsASCVD的危险因素MajorriskfactorsMajorRiskFactors吸烟高血压HDL-C↓糖尿病MajorRiskFactors吸烟EmergingRiskFactors促炎症/促血栓状态某些类型的血脂异常※与动脉粥样硬化及其并发症相关与ASCVD的机制联系尚未完全清楚EmergingRiskFactors促炎症/促UnderlyingRiskFactors 致动脉粥样硬化饮食 肥胖 缺少身体活动 遗传倾向※产生Major/Emergingriskfactors的基础---不健康的生活方式/行为UnderlyingRiskFactors 致动脉粥样AdvancingAge通常列为Majorriskfactor年龄本身不是动脉粥样硬化原因年龄常反应动脉硬化负荷一定年龄的动脉粥样硬化负荷程度明显因人而异年龄不是个体风险的准确指标AdvancingAge通常列为MajorriskfaASCVD一级预防 降胆固醇 控制accelatingriskfactorsMajorEmergingASCVD一级预防 降胆固醇PublicHealthApproachestoPreventionPromotinglifestylebehaviorstopreventRiskfactorsIdentifying/treatingRiskFactorsSmokingHypertensionPublicHealthApproachestoPrAtherogenicCholesterolLDL-Cornon-HDL-Cnon-HDL-C:morestronglyrelatedtoASCVDTC:lessreliableasatargetoftherapyoftenusedinriskassessmentalgorithAtherogenicCholesterolLDL-CHDLPowerfulindicatorofriskKeyroleinglobalriskassessmentHighHDL-CmayprotectagainstASCVDLowHDL-C--amajorriskpredictorofASCVDHDLPowerfulindicatorofriskLifestyleInfluenceonLipoproteins/ASCVDPrevalenceofASCVDdiffersgreatlyindifferentregionsDueinparttogenetic/racialfactorsLifestyleinfluencespredominateLifestyleInfluenceonLipoproLifestyleinfluencesDietTotalcaloricintakeBodyweightPhysicalactivitySmokingaffectLDLHealthylifehabitsadoption↓prevalenceofASCVD↓LifestyleinfluencesDietaffectMajorTargetofTherapyMajorTarget:LDL-CAlternateTarget:non-HDL-CFuture:non-HDL-CwillreplaceLDL-CMajorTargetofTherapyMajorTMajorTargetofTherapyWhynottotalapoB?CostLackofstandardizationLackofconsensusontreatingtargetAdvantageovernon-HDL-CissmallMajorTargetofTherapyWhynotMajorTargetsofTherapyHDL-CUsefulasacomponentofglobalriskassessmentNotprimarytargetofdrugtherapyInterventionoflowHDL-CmainlythroughlifestyletherapiesMajorTargetsofTherapyHDL-COtherLipidRiskFactorsNotincorporatedintoriskassessmenttoolsUtility:limited/uncertainMeasurementsaddexpenseNotrecommendedforroutinetestingLp(a)atmoderatelyhigh/highASCVDriskOtherLipidRiskFactorsNotinOtherLipidRiskFactorsFastingTGUsefulforcalculatingLDL-ClevelsTG↑furthersupportuseofnon-HDL-CasatreatmenttargetOtherLipidRiskFactorsFastinOtherLipidRiskFactorsSmallDenseLipoproteinsDeterminationisanoptionButusefulnessinpredictionortherapyislargelysubsumedbynon-HDL-COtherLipidRiskFactorsSmallOtherLipidRiskFactorsTC/LDL-CratioAddsnothingtoglobalriskassessmentRatioisalreadypartofthelatterTG/HDL-CratioContainedinthemetabolicsyndromeOtherLipidRiskFactorsTC/LDLOtherLipidRiskFactorsLp(a)↑SignifiesagreaterriskNeedformoreintensivemanagementofotherriskfactors,notablyatherogeniccholesterolHighLp-PLA2AppearstobepredictiveofASCVD;Butatpresent,testnotwidelyavailable.OtherLipidRiskFactorsLp(a)Non-LipidEmergingRiskFactorsC-reactiveprotein(CRP)Anoptioninpatientsatmoderatelifetimerisk.Reynoldsriskscore.Non-LipidEmergingRiskFactor如何评估ASCVD风险Short-term(10-years)riskassessmentwithmajorriskFactorsASCVD--1/3higherthanCHD2.Riskassessmentwithmajor+emergingriskfactorsMetabolicsyndromeTG(PROCAM)SmallLDLParticlesCRP(Reynoldsriskscore)如何评估ASCVD风险Short-term(10-yearsRiskAssessmentbyAsImagingCoronaryarterycalcium-CACstronglycorrelatedwithcoronaryarteryplaqueburdenAddspredictivepowerwhencombinedwithFraminghamriskscoringCarotidarterysonographynotasmuchpredictivepowerforCHDusefulforidntificationforstrokeriskRiskAssessmentbyAsImagingCRiskAssessmentbyAsImagingCACCanbeusedasanadjuncttoriskfactorscoringinintermediaterisk(moderate-to-moderatelyhighpatientsCouldbeaguidetointensityofstatintherapyinthesePtsNotwidelyavailableandisrelativelyexpensiveAppropriateapplicationnotwellunderstoodbymostphysicians※NOTapartofROUTINETESTRiskAssessmentbyAsImagingCLimitationof10-yearriskassessment1.Purposeofprimarypreventionistoreducelifetimerisk,not10-yearrisk.2.Estimatesof10-yearriskunderestimatelifetimeriskexceptintheelderlyLimitationof10-yearriskassLong-termriskassessment

lifetimeriskEstimationLloyd-Jones/FraminghamRiskAlgorithmRiskFactorMinor*Moderate*MajorCholesterol(mg/dL)180-199200-239>240SystolicBP(mmHg)120-139140-159>160Cigarettesmoking00+++Diabetes00+++Long-termriskassessment

lifeTotalCVDmorbiditybyage80fromage50(Lloyd-Jones）RiskforCVDMorbiditybyAge80RiskFactorMenWomenNone5%8%≥1minor25%10%≥1moderate38%22%1major45%25%≥2major60%45%TotalCVDmorbiditybyage80Long-termRiskforASCVDbyage80(fromage50)Long-RiskCategoryAbsoluteRiskforASCVDLow<15%Moderate15-30%Moderatelyhigh30-44%High>45%Long-termRiskforASCVDbyagRiskassessmentcalibrationRiskfactorsaffecttotalriskdifferentlyinvariouspopulations.DifferencesinbaselinepopulationriskInherentriskofapopulationbeyondtraditionalriskfactorsAdjustriskscoringfordifferentpopulationsRecalibrateFraminghamscoringforseveralpopulationsRiskassessmentcalibrationRisFraminghamscoringSimilarlypredictedCHDriskinwhitesandblacksOver-predictedriskinseveralEuropeancountriesandinChinaCorrectlyestimatedriskinruralIndiansbutunder-predictedriskinurbanIndiansFraminghamscoringSimilarlyprItaly,China,andJapanBaselinepopulationriskappearstobeunusuallylowLifetimeofrelativelylowLDL-ClevelsHypertension--dominantriskfactorStrokeincidence>CHDItaly,China,andJapanBaselinFHSRecalibrationCoefficientsforCHDChina0.36JapaneseAmerican0.50Germany0.43France0.41Italy0.37Germany0.43Korean1.02(male)0.96(female)UrbanIndia1.81(male)1.54(female)FHSRecalibrationCoefficientsPrimaryPrevention(lifetime)LDL-C/non-HDL-C理想水平LDL-C<100mg/dL(2.6mmol/L)non-HDL-C<130mg/dL(3.4mmol/L)PopulationEpidemiologicalstudiesGeneticstudiesClinicaltrialsPrimaryPrevention(lifetime)PrimaryPrevention(lifetime)OptimallevelsofLDL-C--especiallydesirableinhigh-riskpopulations.Near-optimallevels--acceptableinlow-riskpopulationsorinindividualswithapaucityofotherriskfactors.LDL-C<100-129mg/dL[2.6-3.3mmol/L]或non-HDL-C<130-159mg/dL[3.4-4.1mmol/L]PrimaryPrevention(lifetime)根据长期风险降脂治疗强调风险程度至80岁的风险水平低（小于15%）中（15%-24%）中高（25%-40%）高（>40%）治疗强度--中度中高度高度特殊治疗公众健康指导充分生活方式治疗+降胆固醇药物，首选他汀可选充分生活方式治疗+降胆固醇药物，首选他汀，可考虑充分生活方式治疗+降胆固醇药物，首选他汀，适应证根据长期风险降脂治疗强调风险程度至80岁的低中中高高治疗强度基于非脂质危险因素（吸烟/高血压）的风险较高年青患者

一级预防不一定强调降LDL-C药物

重点戒烟，控制高血压

强调具体的危险因素，而非总体风险基于非脂质危险因素（吸烟/高血压）的风险较高年青患者

一级中度风险人群

生活方式治疗应足以控制风险！

如LDL-C高或很高，可考虑降胆固醇药物

中度风险人群

生活方式治疗应足以控制风险！

如LDL-C高或LifestyletherapyPrimarygoaloflifestyleintervention↓LDL-C/non-HDL-CSecondaryaim↓otherriskfactors.LifestyletherapyPrimarygoalHealthLifestyleBehaviorsCornerstonesforASCVDPrevention/TreatmentHealthyDietaryPatternsCardioprotectiveAchievementofLowLDL-CImprovemrntofotherriskfactorsHealthLifestyleBehaviors药物治疗（较高危患者）他汀为首选药物不能耐受他汀的药物方案更换其他他汀降低他汀剂量隔日服一次他汀使用其他药物--依折麦布、烟酸（单一或联合）强化生活方式治疗药物治疗（较高危患者）他汀为首选药物药物治疗（高危患者）他汀+依折麦布↓理想LDL-C/non-HDL-C药物治疗（高危患者）严重高TG血症非诺贝特或烟酸↓预防急性胰腺炎严重高TG血症二级预防理想LDL-C<70mg/dL(1.8mmol/L)non-HDL-C<100mg/dL(2.6mmol/L)首选大剂量他汀不能耐受大剂量他汀中等剂量他汀联合依折麦布合并高TG他汀联合非诺贝特或烟酸联合用药对比大剂量他汀的证据不足二级预防理想二级预防强调充分生活方式治疗其他危险因素控制戒烟高血压糖尿病二级预防强调充分生活方式治疗总结坚持百年胆固醇学说不动摇危险分层，LDL-C/Non-HDL-C达标策略不变，方案调整ASCVD为不健康生活方式/行为疾病，生活方式治疗是初级/一级预防的基石，二级预防的基础ASCVD防控需国际合作交流，但要结合各国实际：不同国家地区的不同总体人群风险风险评估工具的选择；LDL-C/non-HDL-C干预的目标；肥胖与代谢综合征的诊断标准；药物剂量的需求；生活方式治疗的可行方案总结坚持百年胆固醇学说不动摇寻路走出一条符合中国特色的防控ASCVD的成功之路寻路走出一条符合中国特色的谢谢！谢谢！ACC/AHA胆固醇新指南、

IAS血脂异常管理的全球建议解读

ACC/AHA胆固醇新指南、

IAS血脂异常管理的全球建议解ACC/AHA胆固醇新指南要点完全依据RCT证据聚焦胆固醇---LDL-CACC/AHA胆固醇新指南要点完全依据RCT证据四个需他汀治疗人群ASCVDLDL-C>190mg/dlII型糖尿病40-75岁（LDL-C70-189mg/dl）10年ASCVD风险≥7.5%（LDL-C70-189mg/dl）四个需他汀治疗人群ASCVD三个他汀剂量强LDL-C↓≥50%阿托伐他汀80（40）；瑞舒伐他汀40,20中LDL-C↓30%-50%阿托伐他汀10（20），瑞舒伐他汀5，10；辛伐他汀20，40；普伐他汀40（80）；氟伐他汀80弱LDL-C↓<30%比中等强度剂量更小三个他汀剂量强LDL-C↓≥50%不同人群他汀剂量推荐ASCVDLDL-C>190mg/dlII型糖尿病（40-75岁）10年ASCVD风险≥7.5%大剂量中-大剂量不同人群他汀剂量推荐ASCVD大剂量中-大剂量两个不建议使用他汀人群心功能不全（心功能II-IV级）慢性肾功能不全两个不建议使用他汀人群心功能不全（心功能II-IV级）一个用他汀需谨慎人群年龄≥75岁一个用他汀需谨慎人群年龄≥75岁指南不适宜人群亚裔指南仅适用美国黑人白人指南不适宜人群亚裔设置警戒线LDL-C<40mg/dl设置警戒线LDL-C<40mg/dl不推荐他汀以外的调脂药物依折麦布贝特烟酸血脂康植物甾醇不推荐他汀以外的调脂药物依折麦布IAS建议Panel(15人）Chair:ScottM.Grundy美国Member：HidenoriArai日本 PhilipBarter澳大利亚IAS主席 ThomasP.Bersot美国 D.JohnBetteridge英国 RafaelCarmena西班牙 AdaCuevas智利 MichaelH.Davidson美国 JacquesGenest加拿大 Y.AnteroKesäniemi芬兰 ShaukatSadikot印度 RaulD.Santos巴西 AndreyV.Susekov俄罗斯 RodyG.Sy菲律宾 S.LaleTokgözoglu土耳其 GeraldF.Watts澳大利亚 DongZhao中国IAS建议Panel(15人）Chair:建议的证据基础流行病学研究遗传学研究临床试验（RCT）病理学研究药理学研究代谢研究较小规模临床试验临床试验的荟萃分析动物实验/基础研究建议的证据基础流行病学研究病理学研究RCT的局限性主要为药物试验，生活方式干预试验很少主要在欧美国家人群，其他人群较少入选标准/排除标准，研究对象的代表性局限大多数由制药企业赞助，主要为药物注册上市而非回答临床干预中的临床问题RCT的局限性主要为药物试验，生活方式干预试验很少动脉粥样硬化--生活方式病基于流行病学而非RCT完全依赖RCT的指南重视药物，忽略生活行为二级预防：药物重要一级预防：生活方式干预/改变不健康生活习惯优先动脉粥样硬化--生活方式病基于流行病学而非RCT坚持百年胆固醇学说不动摇血清胆固醇水平↑

→

CHD风险↑血清胆固醇水平低→

CHD风险低降低血清胆固醇→降低CHD风险-RCT流行病学坚持百年胆固醇学说不动摇血清胆固醇水平↑→CH坚持百年胆固醇学说不动摇致动脉粥样硬化脂蛋白LDL一定程度升高---动脉粥样硬化/ASCVD必要条件LDL占致动脉粥样硬化脂蛋白75%Cholesterol-enrichedremnants(富含甘油三酯脂蛋白,即VLDL）25%TG升高时起作用较大VLDL中致动脉粥样硬化的组分是胆固醇，不是TGLDL浸润动脉壁--启动/促进动脉粥样硬化坚持百年胆固醇学说不动摇致动脉粥样硬化脂蛋白LDL一定程度升LDL-C增高单一因素即可致ASCVD家族性高胆固醇血症（FH）（即使无任何其他危险因素）早发动脉粥样硬化和临床ASCVD

--BrownandGoldstein1976LDL-C增高单一因素即可致ASCVD家族性高胆固醇血症（FLDL水平低的人群即使存在其他危险因素（吸烟、高血压、HDL↓、糖尿病）无早发ASCVD---Grundy等1990LDL水平低的人群即使存在其他危险因素LDL升高是“源”其他危险因素是“流”LDL升高

到足以启动动脉粥样硬化程度其他危险因素促进加快动脉粥样硬化ASCVD预防必须聚焦LDL↓并保持终生低水平LDL升高是“源”其他危险因素是“流”LDL升高到足以ASCVD的危险因素MajorriskfactorsEmergingriskfactorsUnderlyingriskfactorsASCVD的危险因素MajorriskfactorsMajorRiskFactors吸烟高血压HDL-C↓糖尿病MajorRiskFactors吸烟EmergingRiskFactors促炎症/促血栓状态某些类型的血脂异常※与动脉粥样硬化及其并发症相关与ASCVD的机制联系尚未完全清楚EmergingRiskFactors促炎症/促UnderlyingRiskFactors 致动脉粥样硬化饮食 肥胖 缺少身体活动 遗传倾向※产生Major/Emergingriskfactors的基础---不健康的生活方式/行为UnderlyingRiskFactors 致动脉粥样AdvancingAge通常列为Majorriskfactor年龄本身不是动脉粥样硬化原因年龄常反应动脉硬化负荷一定年龄的动脉粥样硬化负荷程度明显因人而异年龄不是个体风险的准确指标AdvancingAge通常列为MajorriskfaASCVD一级预防 降胆固醇 控制accelatingriskfactorsMajorEmergingASCVD一级预防 降胆固醇PublicHealthApproachestoPreventionPromotinglifestylebehaviorstopreventRiskfactorsIdentifying/treatingRiskFactorsSmokingHypertensionPublicHealthApproachestoPrAtherogenicCholesterolLDL-Cornon-HDL-Cnon-HDL-C:morestronglyrelatedtoASCVDTC:lessreliableasatargetoftherapyoftenusedinriskassessmentalgorithAtherogenicCholesterolLDL-CHDLPowerfulindicatorofriskKeyroleinglobalriskassessmentHighHDL-CmayprotectagainstASCVDLowHDL-C--amajorriskpredictorofASCVDHDLPowerfulindicatorofriskLifestyleInfluenceonLipoproteins/ASCVDPrevalenceofASCVDdiffersgreatlyindifferentregionsDueinparttogenetic/racialfactorsLifestyleinfluencespredominateLifestyleInfluenceonLipoproLifestyleinfluencesDietTotalcaloricintakeBodyweightPhysicalactivitySmokingaffectLDLHealthylifehabitsadoption↓prevalenceofASCVD↓LifestyleinfluencesDietaffectMajorTargetofTherapyMajorTarget:LDL-CAlternateTarget:non-HDL-CFuture:non-HDL-CwillreplaceLDL-CMajorTargetofTherapyMajorTMajorTargetofTherapyWhynottotalapoB?CostLackofstandardizationLackofconsensusontreatingtargetAdvantageovernon-HDL-CissmallMajorTargetofTherapyWhynotMajorTargetsofTherapyHDL-CUsefulasacomponentofglobalriskassessmentNotprimarytargetofdrugtherapyInterventionoflowHDL-CmainlythroughlifestyletherapiesMajorTargetsofTherapyHDL-COtherLipidRiskFactorsNotincorporatedintoriskassessmenttoolsUtility:limited/uncertainMeasurementsaddexpenseNotrecommendedforroutinetestingLp(a)atmoderatelyhigh/highASCVDriskOtherLipidRiskFactorsNotinOtherLipidRiskFactorsFastingTGUsefulforcalculatingLDL-ClevelsTG↑furthersupportuseofnon-HDL-CasatreatmenttargetOtherLipidRiskFactorsFastinOtherLipidRiskFactorsSmallDenseLipoproteinsDeterminationisanoptionButusefulnessinpredictionortherapyislargelysubsumedbynon-HDL-COtherLipidRiskFactorsSmallOtherLipidRiskFactorsTC/LDL-CratioAddsnothingtoglobalriskassessmentRatioisalreadypartofthelatterTG/HDL-CratioContainedinthemetabolicsyndromeOtherLipidRiskFactorsTC/LDLOtherLipidRiskFactorsLp(a)↑SignifiesagreaterriskNeedformoreintensivemanagementofotherriskfactors,notablyatherogeniccholesterolHighLp-PLA2AppearstobepredictiveofASCVD;Butatpresent,testnotwidelyavailable.OtherLipidRiskFactorsLp(a)Non-LipidEmergingRiskFactorsC-reactiveprotein(CRP)Anoptioninpatientsatmoderatelifetimerisk.Reynoldsriskscore.Non-LipidEmergingRiskFactor如何评估ASCVD风险Short-term(10-years)riskassessmentwithmajorriskFactorsASCVD--1/3higherthanCHD2.Riskassessmentwithmajor+emergingriskfactorsMetabolicsyndromeTG(PROCAM)SmallLDLParticlesCRP(Reynoldsriskscore)如何评估ASCVD风险Short-term(10-yearsRiskAssessmentbyAsImagingCoronaryarterycalcium-CACstronglycorrelatedwithcoronaryarteryplaqueburdenAddspredictivepowerwhencombinedwithFraminghamriskscoringCarotidarterysonographynotasmuchpredictivepowerforCHDusefulforidntificationforstrokeriskRiskAssessmentbyAsImagingCRiskAssessmentbyAsImagingCACCanbeusedasanadjuncttoriskfactorscoringinintermediaterisk(moderate-to-moderatelyhighpatientsCouldbeaguidetointensityofstatintherapyinthesePtsNotwidelyavailableandisrelativelyexpensiveAppropriateapplicationnotwellunderstoodbymostphysicians※NOTapartofROUTINETESTRiskAssessmentbyAsImagingCLimitationof10-yearriskassessment1.Purposeofprimarypreventionistoreducelifetimerisk,not10-yearrisk.2.Estimatesof10-yearriskunderestimatelifetimeriskexceptintheelderlyLimitationof10-yearriskassLong-termriskassessment

lifetimeriskEstimationLloyd-Jones/FraminghamRiskAlgorithmRiskFactorMinor*Moderate*MajorCholesterol(mg/dL)180-199200-239>240SystolicBP(mmHg)120-139140-159>160Cigarettesmoking00+++Diabetes00+++Long-termriskassessment

lifeTotalCVDmorbiditybyage80fromage50(Lloyd-Jones）RiskforCVDMorbiditybyAge80RiskFactorMenWomenNone5%8%≥1minor25%10%≥1moderate38%22%1major45%25%≥2major60%45%TotalCVDmorbiditybyage80Long-termRiskforASCVDbyage80(fromage50)Long-RiskCategoryAbsoluteRiskforASCVDLow<15%Moderate15-30%Moderatelyhigh30-44%High>45%Long-termRiskforASCVDbyagRiskassessmentcalibrationRiskfactorsaffecttotalriskdifferentlyinvariouspopulations.DifferencesinbaselinepopulationriskInherentriskofapopulationbeyondtraditionalriskfactorsAdjustriskscoringfordifferentpopulationsRecalibrateFraminghamscoringforseveralpopulationsRiskassessmentcalibrationRisFraminghamscoringSimilarlypredictedCHDriskinwhitesandblacksOver-predictedriskinseveralEuropeancountriesandinChinaCorrectlyestimatedriskinruralIndiansbutunder-predictedriskinurbanIndiansFraminghamscoringSimilarlyprItaly,China,andJapanBaselinepopulationriskappearstobeunusuallylowLifetimeofrelativelylowLDL-ClevelsHypertension--dominantriskfactorStrokeincidence>CHDItaly,China,andJapanBaselinFHSRecalibrationCoefficientsforCHDChina0.36JapaneseAmerican0.50Germany0.43France0.41Italy0.37