血脂治疗与临床指南.ppt

1、JNC 7: Classification and Management of Blood Pressure for Adults*,*Treatment determined by highest BP categoryTreat patients with chronic kidney disease or diabetes to BP goal of 130/80 mm HgInitial combined therapy should be used cautiously in those at risk for orthostatic hypotension SBP=systolic

2、 blood pressure; DBP=diastolic blood pressure; ACEI=angiotensin- converting enzyme inhibitor; ARB=angiotensin receptor blocker; BB=b-blocker; CCB=calcium channel blocker JNC 7. May 2003. NIH publication 03-5233.,JNC 7: Treatment Algorithm for Hypertension,SBP=systolic blood pressure; DBP=diastolic b

3、lood pressure; ACEI=angiotensin- converting enzyme inhibitor; ARB=angiotensin receptor blocker; BB=b-blocker; CCB=calcium channel blocker JNC 7. May 2003. NIH publication 03-5233.,Not at goal blood pressure,Lifestyle modifications,Not at goal blood pressure (140/90 mm Hg)(130/80 mm Hg for those with

4、 diabetes or chronic kidney disease),Initial drug choices,ATP III: New Features of GuidelinesFocus on Multiple Risk Factors,Persons with diabetes without CHD raised to level of CHD risk equivalent Framingham 10-year absolute CHD risk projections used to identify certain patients with 2 risk factors

5、for more intensive treatment Persons with multiple metabolic risk factors (the metabolic syndrome) identified as candidates for intensified therapeutic lifestyle changes (TLC),Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III:

6、New Features of GuidelinesApplying the Recommendations,Complete fasting lipoprotein profile (TC, LDL-C, HDL-C, TG) recommended as preferred initial test Use of plant stanols/sterols and viscous fiber encouraged as therapeutic dietary options to enhance LDL-C lowering Strategies presented to improve

7、adherence to therapeutic lifestyle changes (TLC), drug therapies Intensive TLC recommended for persons with the metabolic syndrome NonHDL-C (TC minus HDL-C) goal recommended as secondary target for persons with high TG levels (200 mg/dL),Expert Panel on Detection, Evaluation, and Treatment ofHigh Bl

8、ood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III: Features Shared with ATP II,LDL-C lowering remains primary goal of therapy High LDL-C (160 mg/dL) considered target for LDL-Clowering drug therapy Intensive LDL-C lowering emphasized in persons with CHD 3 risk categories for different LDL

9、-C goals and intensities of LDL-Clowering therapy Subpopulations (other than middle-aged men) identified for detection of high LDL-C, clinical intervention: young adults; postmenopausal women; older persons Weight loss, physical activity emphasized to reduce risk in persons with elevated LDL-C,Exper

10、t Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III: LDL-C, HDL-C, TC Classification,Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III: Major CHD Risk FactorsOth

11、er Than LDL-C,Cigarette smoking Hypertension: BP 140/90 mm Hg or on antihypertensive medication Low HDL-C: 40 mg/dL* Family history of premature CHD (1st-degree relative): male relative age 55 years female relative age 65 years Age male 45 years female 55 years,*HDL-C 60 mg/dL is a negative risk fac

12、torand negates one other risk factor.,Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III: Additional CHD Risk Factors,Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2

13、497.,Life-habit risk factors: targets for intervention; not usedto set lower LDL-C goal obesityphysical inactivityatherogenic diet Emerging risk factors: can help guide intensity of risk-reduction therapy; do not categorically alter LDL-C goals lipoprotein(a)homocysteineimpaired fasting glucoseproth

14、rombotic and subclinical atheroscleroticproinflammatory factors disease,ATP III: Assessment of Risk,For persons without known CHD, other forms of atherosclerotic disease, or diabetes: Count the number of risk factors. Use Framingham scoring for persons with 2 risk factors* to determine the absolute

15、10-year CHD risk.,*For persons with 01 risk factor, Framingham calculations are not necessary.,Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III: Risk Categories, LDL-C Goals,*Almost all people with 01 risk factor have a 10-yea

16、r risk 10%;thus, Framingham risk calculations are not necessary.,Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III: CHD Risk EquivalentsRisk for major coronary events equal to that of established CHD (20% per 10 years),Other cl

17、inical forms of atherosclerotic disease peripheral arterial disease (PAD) abdominal aortic aneurysm (AAA) carotid artery disease Diabetes Multiple risk factors*,Adult Treatment Panel III. NIH publication 01-3095.,*Determined with ATP III Framingham risk scoring.,ATP III: LDL-C Treatment Cutpoints fo

18、r Therapy,*Therapeutic lifestyle changes Some authorities use LDL-Clowering drugs if TLC does not achieve LDL-C 100 mg/dL; others use drugs to modify HDL-C and TG.,Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III: Nutritional

19、Components of the TLC Diet,Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,*Trans fatty acids also raise LDL-C and should be kept at a low intake. Note: Regarding total calories, balance energy intake and expenditure tomaintain desir

20、able body weight.,ATP III: Additional Dietary Options for LDL-C Lowering,Viscous (soluble) fiber: 510 g/day eg, oats, guar, pectin, psyllium Plant stanols/sterols: 2 g/day available in commercial margarines with intake of fruits and vegetables Soy protein: 2540 g/day when replacing animal food produ

21、cts,Adult Treatment Panel III. NIH publication 01-3095.,ATP III: Management of Very High LDL-C,LDL-C 190 mg/dL usually traced to genetic formsof hypercholesterolemia Recommended actions: early detection in young adults through cholesterolscreening to prevent premature CHD family cholesterol testing

22、to identify affected relatives combination drug therapy usually required to achieve target LDL-C levels,Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III: Management of Low HDL-C,Low HDL-C: 40 mg/dL (no specific goal defined fo

23、r raising HDL-C) Targets of therapy: all persons with low HDL-C: achieve LDL-C goal; then weight, physical activity (if metabolic syndrome is present) those with TG 200499 mg/dL: achieve nonHDL-C goal* as secondary priority those with TG 200 mg/dL: consider drugs for raising HDL-C (fibrates, nicotin

24、ic acid),Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,*NonHDL-C goal is set at 30 mg/dL higher than LDL-C goal.,Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,*Pr

25、imary aim of therapy is to get to LDL-C goal. Primary aim of therapy is to reduce risk for pancreatitis through TG lowering first, then focus on LDL-C. To achieve nonHDL-C goal (set at 30 mg/dL higher than LDL-C goal), intensify therapy with LDL-Clowering drug, or add nicotinic acid or fibrate.,ATP

26、III: Management of Elevated TG,ATP III: The Metabolic SyndromeDiagnosis is established when 3 of these risk factors are present.,*Abdominal obesity is more highly correlated with metabolic risk factors than is BMI. Some men develop metabolic risk factors when circumference is only marginally increas

27、ed.,Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III: Management of Diabetic Dyslipidemia,Primary target of therapy: identification of LDL-C; goal for persons with diabetes: 100 mg/dL Therapeutic options: LDL-C 100129 mg/dL: i

28、ncrease intensity of TLC; add drug to modify atherogenic dyslipidemia (fibrate or nicotinic acid); intensify risk factor control LDL-C 130 mg/dL: simultaneously initiate TLC and LDL-Clowering drugs TG 200 mg/dL: nonHDL-C* becomes secondary target,Expert Panel on Detection, Evaluation, and Treatment

29、ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,Note: Diabetic dyslipidemia is essentially atherogenic dyslipidemia in persons with type 2 diabetes.*NonHDL-C goal is set at 30 mg/dL higher than LDL-C goal.,ATP III: LDL-C Measurements in Patients Hospitalized for Major Coronary Events,M

30、easure LDL-C on admission or within 24 hours General recommendations at discharge: LDL-C 130 mg/dL: discharge on drug therapy LDL-C 100129 mg/dL: use clinical judgment* Advantages of initiating drug therapy at discharge: motivates patients to begin/continue risk-lowering therapy emphasizes consisten

31、cy and continuous follow-up; no “treatment gap” may reduce early clinical events,Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,*Some authorities recommend initiating lower-dose drug therapy when LDL-C 100 mg/dL in patients with CHD

32、-related illness.,ATP III: Special PopulationsWomen, Middle-Aged Men,Women (4575 years of age) onset of most CHD occurs 65 years of age (premature CHD 65 years of age attributed to multiple risk factors, metabolic syndrome) HRT use for CHD risk reduction not supported by clinical trial results; chol

33、esterol-lowering therapy (statins) has been shown to reduce CHD risk and is recommended Middle-Aged Men (3565 years of age) high prevalence of major risk factors; predisposed to abdominal obesity, metabolic syndrome intensive LDL-Clowering recommended for those at relatively high CHD risk,Expert Pan

34、el on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III: Special PopulationsOlder Adults, Younger Adults,Older Adults (men 65 years of age; women 75 years of age) first-line therapy: TLC; for higher risk, consider LDL-Clowering drug Younger Ad

35、ults (men 2035 years of age; women 2045 years of age) risk-factor identification important for long-term prevention LDL-C 130 mg/dL: emphasize TLC men with LDL-C 160189 mg/dL who smoke: consider LDL-Clowering drug all young adults with LDL-C 190 mg/dL warrant drug therapy,Expert Panel on Detection,

36、Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III: Improving AdherenceFocus on the Patient,For optimum effectiveness, physicians should employ 2 of these approaches for each patient: Keep medication regimens simple Make instructions very explicit Suggest

37、 use of prompts Utilize systems to maintain patient contact Encourage support from family, friends Reinforce, reward adherence Increase visits for those who cannot reach treatment goal Make care more convenient, accessible Encourage self-monitoring,Expert Panel on Detection, Evaluation, and Treatmen

38、t ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III: Improving AdherenceFocus on the Physician, Delivery System,For the physician, medical office: Use prompts to highlight lipid management Identify an in-office patient advocate Involve patients to prompt preventive care Use feedb

39、ack to modify future care For the health delivery system: Provide lipid management through a lipid clinic Utilize case management by nurses Implement telemedicine (phone follow-up) procedures Involve pharmacists in collaborative care Develop in-hospital critical care pathways,Expert Panel on Detecti

40、on, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA. Expert Panel on Detection, Evaluation, and Treatment of High Bl

41、ood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,Assessing CHD Risk in Men,Step 2: Total Cholesterol,TC Points atPoints atPoints atPoints atPoints at(mg/dL) Age 20-39Age 40-49Age 50-59Age 60-69Age 70-79 16000000 160-19943210 200-23975310 240-27996421 280118531,Point Total10-Year RiskPoint Total1

42、0-Year Risk 01%118% 01%1210% 11%1312% 21%1416% 31%1520% 41%1625% 52%1730% 62% 73% 84% 95% 106%,Step 7: CHD Risk,ATP III Framingham Risk Scoring,Point Total10-Year RiskPoint Total10-Year Risk 91%2011% 91%2114% 101%2217% 111%2322% 121%2427% 132% 25 30% 142% 153% 164% 175% 186% 198%,Assessing CHD Risk

43、in Women,Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.,TC Points atPoints atPoints at

44、Points atPoints at(mg/dL) Age 20-39Age 40-49Age 50-59Age 60-69Age 70-79 16000000 160-19943211 200-23986421 240-279118532 2801310742,Step 7: CHD Risk,Step 2: Total Cholesterol,ATP III Framingham Risk Scoring,Step 1: Age,Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in

45、Adults. JAMA. 2001;285:2486-2497.,ATP III Framingham Risk Scoring,Step 2: Total Cholesterol,Note: TC and HDL-C values should be the average of at least two fasting lipoprotein measurements. Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2

46、497.,Men,TC Points atPoints atPoints atPoints atPoints at(mg/dL) Age 20-39Age 40-49Age 50-59Age 60-69Age 70-79 16000000 160-19943210 200-23975310 240-27996421 280118531,Women,TC Points atPoints atPoints atPoints atPoints at(mg/dL) Age 20-39Age 40-49Age 50-59Age 60-69Age 70-79 16000000 160-19943211 2

47、00-23986421 240-279118532 2801310742,ATP III Framingham Risk Scoring,Step 3: HDL-Cholesterol,Note: HDL-C and TC values should be the average of at least two fasting lipoprotein measurements. Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-

48、2497.,Men,Women,ATP III Framingham Risk Scoring,Step 4: Systolic Blood Pressure,Note: The average of several BP measurements is needed for an accuratemeasurement of baseline BP. If an individual is on antihypertensive treatment,extra points are added. Expert Panel on Detection, Evaluation, and Treat

49、ment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III Framingham Risk Scoring,Step 5: Smoking Status,Note: Any cigarette smoking in the past month. Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III Framingh

50、am Risk Scoring,Step 6: Adding Up the Points(Sum From Steps 15),Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III Framingham Risk Scoring,Step 7: CHD Risk for Men,Note: Determine the 10-year absolute risk for hard CHD (MI and c

51、oronary death) from point total. Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III Framingham Risk Scoring,Step 7: CHD Risk for Women,Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point tot

52、al. Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.,ATP III Framingham Risk Scoring,ATP II,ATP III,Study population (millions),ATP III vs ATP II: Increases in Treatment-Eligible Primary-Prevention Patients,Data from Fedder DO et al.

53、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),45 y,65 y,*All values in millions. Conservative=therapy initiated at higher LDL-C threshold; liberal=therapy initiated at lower drug-optional LDL-C range. Adapted f

54、rom Fedder DO et al. Circulation. 2002;105:152-156.,Eligible Primary-Prevention Patients by Age and Treatment Scenario (ATP III vs ATP II)*,hs-CRP measurement is independent marker of CVD risk In patients at intermediate risk (10%20% risk of CHD per 10 years): hs-CRP may help direct further evaluati

55、on, therapy in primary prevention In patients with stable coronary disease,acute coronary syndromes: hs-CRP measurement may be useful as independent marker of prognosis for recurrent events,AHA/CDC Panel: Recommendations for Use of hs-CRP in Clinical Practice,Pearson TA et al. Circulation. 2003;107:

56、499-511.,Measurements of hs-CRP: should be performed twice (2 weeks apart) results averaged, expressed as mg/L fasting or nonfasting, in metabolically stable patients if level 10 mg/L, test should be repeated, patient examined for sources of infection or inflammation Relative risk categories for hs-

57、CRP levels: low3.0 mg/L,AHA/CDC Panel: Recommendations for hs-CRP Laboratory Testing,Pearson TA et al. Circulation. 2003;107:499-511.,2004 PPS,0,20,40,60,80,100,Lipid Lowering,LDL-C,BP Control,%,LaBresh KA et al. Arch Intern Med. 2004;164:203-209.,*Based on AHA/ACC secondary-prevention guidelines. L

58、ipid lowering indicates use of lipid-lowering agents at discharge; low-density lipoprotein cholesterol (LDL-C) level determined in hospital; blood pressure (BP) 140/90 mm Hg at time of discharge. P0.05; significance based on nonoverlapping 95% confidence intervals compared with baseline.,N=1,738,AHA

59、 Get With the Guidelines: Adherence to Treatment Measures*,2004 PPS,AHA Evidence-Based Guidelines for CVD Prevention in Women,Key Strategies for Clinical Practice Assess, stratify based on risk, treat according to risk category Urge lifestyle changes 30 minutes moderate-intensity physical activity daily Smoking cessation Weight maintenance/reduction Heart-healthy diet Encourage optimal BP 50 mg/dL TG 150 mg/dL NonHDL-C 130 mg/dL,Expert Panel/Writing Group. Circulation. 2004;109:672-693.,2004 PPS,AHA Evidenc