血脂治疗与临床指南
JNC 7: Classification and Management of Blood Pressure for Adults*
*Treatment determined by highest BP category ?Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mm Hg ?Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension
SBP=systolic 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 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.
Lifestyle modifications
ATP III: New Features of Guidelines— Focus 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 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 of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
ATP III: New Features of Guidelines—Applying 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 adherence to therapeutic lifestyle changes (TLC), drug therapies
Intensive TLC recommended for persons with the metabolic syndrome
Non–HDL-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 of High Blood 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-C–lowering drug therapy
Intensive LDL-C lowering emphasized in persons with CHD
3 risk categories for different LDL-C goals and intensities of LDL-C–lowering 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
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
ATP III: LDL-C, HDL-C, TC Classification
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
ATP III: Major CHD Risk Factors Other 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 factor and negates one other risk factor.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
ATP III: Additional CHD Risk Factors
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
Life-habit risk factors: targets for intervention; not used to set lower LDL-C goal
– obesity – physical inactivity – atherogenic diet
Emerging risk factors: can help guide intensity of risk-reduction therapy; do not categorically alter LDL-C goals
– lipoprotein(a) – homocysteine – impaired fasting glucose – prothrombotic and – subclinical atherosclerotic proinflammatory 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 10-year CHD risk.
*For persons with 0–1 risk factor, Framingham calculations are not necessary.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
ATP III: Risk Categories, LDL-C Goals
*Almost all people with 0–1 risk factor have a 10-year risk <10%; thus, Framingham risk calculations are not necessary.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
ATP III: CHD Risk Equivalents Risk for major coronary events equal to that of established CHD (>20% per 10 years)
Other clinical 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 for Therapy
*Therapeutic lifestyle changes
?Some authorities use LDL-C–lowering 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 of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
ATP III: Nutritional Components of the TLC Diet
Expert Panel on Detection, Evaluation, and Treatment of High 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 to maintain desirable body weight.
ATP III: Additional Dietary Options for LDL-C Lowering
Viscous (soluble) fiber: 5–10 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: ?25–40 g/day when replacing animal food products
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 forms of hypercholesterolemia
Recommended actions:
early detection in young adults through cholesterol screening to prevent premature CHD
family cholesterol testing to identify affected relatives
combination drug therapy usually required to achieve target LDL-C levels
Expert Panel on Detection, Evaluation, and Treatment of High 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 for 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 200–499 mg/dL: achieve non–HDL-C goal* as secondary priority
those with TG <200 mg/dL: consider drugs for raising HDL-C (fibrates, nicotinic acid)
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
*Non–HDL-C goal is set at 30 mg/dL higher than LDL-C goal.
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.
*Primary 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 non–HDL-C goal (set at 30 mg/dL higher than LDL-C go