HDL和冠心病
HDL and Coronary Heart Disease
Epidemiology of CHD
HDL-C Distribution in US Adults
RF = risk factors
Data from NHANES III, 1988–1994
HDL-C (mg/dL)
< 35
35–< 45
45–< 60
? 60
CHD
0
2
4
6
8
10
12
14
16
? 2 RF, no CHD
No. of US adults (millions)
CHD Risk According to HDL-C Levels Framingham Study
4.0
3.0
2.0
1.0
25
45
65
HDL-C (mg/dL)
CHD risk ratio
Kannel WB. Am J Cardiol 1983;52:9B–12B.
Copyright ?1983, with permission from Excerpta Medica Inc.
2.0
1.0
0
4.0
CHD Risk According to Total-C/HDL-C Ratio Framingham Study (Men)
Kannel WB. Am J Cardiol 1987;59:80A–90A
3.0
2.5
2.0
1.5
1.0
0.5
2.0
4.0
6.0
8.0
10.0
12.0
Total-C/HDL-C ratio
CHD risk ratio
3.4
4.4
9.6
CHD Risk According to HDL-C Levels Prospective Cardiovascular Münster Study
110
30
21
0
20
40
60
80
100
120
< 35
35–55
> 55
Incidence
per 1,000 (in 6 years)
HDL-C (mg/dL)
Assmann G, ed. Lipid Metabolism Disorders and Coronary Heart Disease. Munich: MMV Medizin Verlag, 1993
186 events in 4,407 men (aged 40–65 y)
Low HDL-C Levels Increase CHD Risk Even When Total-C Is Normal (Framingham)
Risk of CHD by HDL-C and Total-C levels; aged 48–83 y
Castelli WP et al. JAMA 1986;256:2835–2838
0
2
4
6
8
10
12
14
< 40
40–49
50–59
? 60
< 200
230–259
200–229
? 260
HDL-C (mg/dL)
Total-C (mg/dL)
14-y incidence rates (%) for CHD
11.24
11.91
12.50
11.91
6.56
4.67
9.05
5.53
4.85
4.15
3.77
2.78
2.06
3.83
10.7
6.6
Hypertriglyceridemia Increases CHD Risk in Patients with Low HDL-C Levels Prospective Cardiovascular Münster Study
* Bar represents 5% of subjects in which 25% of CHD events occurred.
Assmann G, Schulte H. Am J Cardiol 1992;70:733–737.
Copyright ?1992, with permission from Excerpta Medica Inc.
24
31
116
245
0
50
100
150
200
250
? 5.0
> 5.0
*
LDL-C/HDL-C ratio
Incidence
per 1,000 (in 6 years)
TG < 200 mg/dL
TG ? 200 mg/dL
Frequency of Low HDL-C Compared With Other Risk Factors in Men With Premature CHD
Cases
Controls (n = 321)
Risk factor (n = 601) Not adjusted Adjusted
Cigarette smoking 29% 67%* —
HDL-C ? 35 mg/dL 19% 63%* 57%*
Hypertension (BP ? 150/90) 21% 41%* —
LDL-C ? 160 mg/dL 26% 26% 34%*
Diabetes mellitus 1% 12%* —
*Significantly different from controls (P < 0.001)
Genest JJ et al. Am J Cardiol 1991;67:1185–1189
Distribution of HDL-C Levels in Men With CHD VA-HIT Study Group
HDL-C level Whites Blacks All subjects
(mg/dL) (n = 2,891) (n = 572) (n = 8,578)
< 35 42% 20% 38%
35–40 25% 23% 25%
> 40 32% 57% 36%
Rubins HB et al. Am J Cardiol 1995;75:1196–1201
}
63%
CHD Incidence Related to HDL-C Levels in Various Trials
95% confidence intervals (CIs) for adjusted proportional hazards regression coefficients. FHS = Framingham Heart Study; LRCF = Lipid Research Clinics Prevalence Mortality Follow-up Study; CPPT = Lipid Research Clinics Coronary Primary Prevention Trial; MRFIT = Multiple Risk Factor Intervention Trial
Gordon DJ et al. Circulation 1989;79:8–15
% change in risk per 1 mg/dL increment in HDL-C
0
-2
-4
-6
-8
-10
FHS
LRCF
CPPT
MRFIT
FHS
LRCF
CHD incidence
Men
Women
Population, Gender, and Ethnic Variability in HDL-C Levels
Mean HDL-C level (mg/dL)
Population Men Women
United States (NHANES III)1
Whites 44 54
African-Americans 51 55
Turkey (Turkish Heart Study)2 37 42
1. NHANES III, 1988–1994 (unpublished data)
2. Mahley RW et al. J Lipid Res 1995;36:839–859
Ethnic Variations in Lipid Parameters Insulin Resistance Atherosclerosis Study
African- Non-Hispanic
Americans Hispanics Whites P value
n 462 (27%) 546 (34%) 612 (38%) < 0.001
Total-C (mg/dL) 212.5 211.1 213.2 0.782
LDL-C (mg/dL) 143.8 139.4 140.7 0.410
HDL-C (mg/dL) 47.0 42.3 44.0 < 0.001
TG (mg/dL) 102.1 147.7 134.0 < 0.001
LDL size (?) 262.1 257.6 259.2 < 0.001
Haffner SM et al. Arterioscler Thromb Vasc Biol 1999;19:2234–2240.
Changing Mortality Rates Over Time for CHD in Patients With and Without Diabetes
Subjects aged 35–74 y
Gu K et al. JAMA 1999;281:1291–1297
17
7.4
14.2
4.2
6.8
2.4
7.6
1.9
0
2
4
6
8
10
12
14
16
18
-16.6%
(P = 0.46)
+10.7%
(P = 0.76)
-43.8%
(P < 0.001)
-20.4%
(P = 0.12)
Men (NHANES I, 1971–75)
Men (NHEFS, 1982–84)
Women (NHANES I, 1971–75)
Women (NHEFS, 1982–84)
Diabetic
Nondiabetic
}
}
}
}
Mortality rate (%)
per 1,000 person-years
Differences in CVD Risk Factors by Diabetes Status in Men and Women The Strong Heart Study
-7.5*
Men (n = 1,846)
Women (n = 2,703)
*P = 0.0005; ?P = 0.0120
Adapted from Howard BV et al. Diabetes Care 1998;21:1258–1265
-4.4
-3.7
-5.3?
-8
-7
-6
-5
-4
-3
-2
-1
0
HDL-C
(mg/dL)
LDL size
(?)
Differences between subjects with and without diabetes
Native Americans
Probability of Death From CHD in Patients With NIDDM and in Nondiabetic Patients, With and Without Prior MI
Kaplan-Meier estimates
Haffner SM et al. N Engl J Med 1998;339:229–234.
? Copyright 1998, Massachusetts Medical Society. All rights reserved.
0
1
2
3
4
5
6
7
8
0
20
40
60
80
100
Nondiabetic subjects without prior MI
Diabetic subjects without prior MI
Nondiabetic subjects with prior MI
Diabetic subjects with prior MI
Years
Survival (%)
Potential Risk Factors for CHD in 2,693 White Patients With NIDDM United Kingdom Prospective Diabetes Study
280 pts with CHD
Turner RC et al. BMJ 1998;316:823–828
1
1
1
1.48
0.87
1.63
2.29
0.51
1.93
0
0.5
1.0
1.5
2.0
2.5
LDL-C
HDL-C
TG
Tertile
Tertile
Tertile
Estimated hazard ratio
P < 0.001
P < 0.001
P < 0.001
Stepwise Selection of Risk Factors in 2,693 White Patients With NIDDM United Kingdom Prospective Diabetes Study
Coronary heart disease (n = 280)
Position in model Variable P value
1st LDL-C <0.0001
2nd HDL-C 0.0001
3rd Hemoglobin A1c 0.0022
4th Systolic blood pressure 0.0065
5t