急性冠脈綜合征的降脂治療

1、急性冠脈綜合癥的降脂治療Lipid-lowering treatment of acute coronary syndrome,北京市昌平中醫(yī)醫(yī)院：張碎虎,Contents,ACS病理基礎(chǔ),ACS病理基礎(chǔ),ACS斑塊特征,①大脂池（脂質(zhì)核心占40%）②大量炎性細(xì)胞浸潤(rùn)③易損性（vulnerability） ★血中血脂異常增高 ★內(nèi)皮細(xì)胞功能損傷 ★局部炎癥 ★血液動(dòng)力學(xué)異常,李嬌嬌.心血管病防治知識(shí)(下半月),20

2、19,12:150-153,,,ACS與血脂狀態(tài),有報(bào)道ACS患者應(yīng)激狀態(tài)下，血脂濃度有較大波動(dòng)。AMI發(fā)生24h后，TC、LDL-C、HDL-C、apoA1和apoB均有明顯下降，TG卻增加。4～5d后變化最為明顯，2～3個(gè)月后可回到基線狀態(tài)。此時(shí)LDL和HDL顆粒性質(zhì)發(fā)生了變化。作者認(rèn)為，對(duì)于ACS患者，無(wú)論基線血脂濃度如何，都需要積極地應(yīng)用他汀類(lèi)藥物進(jìn)行強(qiáng)化降脂治療。,趙水平.中華心血管病雜志,2019,41(7):&

3、#160;542-543,ACS血脂狀態(tài),有人對(duì)59例ACS患者急性期24h內(nèi)的血脂6項(xiàng)指標(biāo)（TC、TG、HDL-C、LDL-C和ApoB、apoA1）與47例健康人的水平進(jìn)行了比較,結(jié)果,結(jié)論：TC、TG、LDL-C、ApoB水平升高和HDL-C、ApoA1水平降低可能是ACS發(fā)病的危險(xiǎn)因素，血脂6項(xiàng)指標(biāo)聯(lián)合檢測(cè)有助于預(yù)測(cè)ACS的發(fā)生并監(jiān)控病情的變化。,丁玲新等. 海南醫(yī)學(xué)院學(xué)報(bào),2019,11:1476-1478,ACS與

4、血脂狀態(tài),另一篇報(bào)道：經(jīng)冠脈造影診斷為CHD的367例患者，其中男性261例，女性106例，年齡29～89(59.5±11.0)歲。268例ACS患者，99例非ACS患者作為對(duì)照，對(duì)兩組患者的Lp(a)、HDL-C、ApoAl、TC、TG、LDL-C以及ApoB水平進(jìn)行觀察。,結(jié)果,結(jié)論,Lp(a)、HDL-C和ApoAl的水平在ACS患者和對(duì)照組患者中差異有統(tǒng)計(jì)學(xué)意義，提示我們?cè)谥匾暯档突颊叩腡C,TG和LDL

5、-C水平的同時(shí)，也應(yīng)該關(guān)注HDL-C, ApoA1和Lp(a)水平的影響,曲環(huán).中國(guó)心血管病研究,2019,6(6):410-412,ACS與血脂狀態(tài),另一項(xiàng)研究納入333例ACS患者，男性232例（69.7%），女性101例（30.3%），年齡62±10.63歲。其中UA257例（77.2%），NSTEMI50例，STEMI26例（7.8%），在發(fā)病期對(duì)患者血漿血脂濃度進(jìn)行檢測(cè)。,結(jié)果,結(jié)論,1.在ACS患者中，血

6、脂異常較為常見(jiàn)2.大于50%是HDL-C＜1.0mmol/L,孫斌.鄭州大學(xué),2019年,學(xué)位論文,,,,周亞玲.檢驗(yàn)醫(yī)學(xué)與臨床,2019,z2:278-279,,Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study: a ran

7、domized controlled trial.,★A randomized, double-blind trial ★2019.5 to 2019.9★follow-up 16 weeks ★122 clinical centers in Europe, NorthAmerica, South Africa, and Australasia.,★A total of 3086 adults aged 18 years or

8、older with unstable angina or non-Q-wave acute myocardial infarction.★①To determine whether treatment with atorvastatin ②80 mg/d atorvastatin, initiated 24 to 96 hours after an acute coronary

9、syndrome,★Primary end point :death, nonfatal acute myocardial infarction, cardiac arrest with resuscitation, or recurrent symptomatic myocardial ischemia with objective evidence and requiring emergency rehospitalization.

10、,Rulst,,Conclusion,For patients with acute coronary syndrome, lipid-lowering therapy with atorvastatin, 80 mg/d, reduces recurrent ischemic events in the first 16 weeks, mostly recurrent symptomatic ischemia requiri

11、ng rehospitalization.,Schwartz GG，et al. JAMA. 2019 Apr 4;285(13):1711-8.,Early Intensive vs a Delayed Conservative Simvastatin Strategy in Patients With Acute Coronary Syndromes Phase Z of the A to Z Trial

12、,JAMA. 2019;292(11):1307-1316. doi:10.1001/jama.292.11.1307.,A to Z(the Aggrastat to Zocor）,Time: December 29, 2019, and January 6, 2019Design: ①patients(n = 2265) with ACS receiving 40 mg/d of simvastat

13、in for 1 month followed by 80 mg/d ②patients(n = 2232) with ACS patients receiving placebo for 4 months followed by 20 mg/d of simvastatin,Follow-up : 6～ 24months.The primary end point: Cardiovascular death

14、 Nonfatal myocardial infarction Readmission for ACS Stroke,simvastatin,,Among patients with ACS, the early initiation of an aggressive simvastatin regimen resulted in a favorable trend toward red

15、uction of major cardiovascular events.,Conclusions,ARMYDA Trial,Pasceri V, et alCirculation 2019;110:674-8,Atorvastatin for Reduction of Myocardial Damage During Angioplasty,153 patients scheduled for elective PCI irr

16、espective of baseline lipid levelsRandomized, double-blind,Atorvastatin40 mg/d n=76,Placebo n=77,End Points,★The primary end point ：occurrence of myocardial infarction（CK-MB >2 times ）★Secondary end points ：①ot

17、her markers of myocardial injury（CK-MB, troponin I and myoglobin）＞upper normal limits②mean peak values of CK-MB, troponin I and myoglobin after intervention③occuring adverse cardiac events (death, myocardial infarction

18、, or need for unplanned revascularization) Within a month,ARMYDA Trial,Primary endpoint of post-procedure MI (CKMB>2x ULN) ↓ in atorvastatin group vs placebo (Figure) Presence of markers >1x ULN also ↓ in atorvas

19、tatin arm: CKMB 12% vs 35%, p=0.001; troponin I 20% vs 48% p=0.0004; myoglobin 22% vs 51%, p=0.0005,Circulation 2019;110:674-8,Post-procedure MI(>2x ULN)p = 0.025,ARMYDA Trial,Circulation 2019;110:674-8,Peak values

20、of CK-MB, troponin I, and myoglobin in statin vs placebo group. Data are mean±SEM.,pretreatment with atorvastatin significantly reduced risk of periprocedural myocardial infarction (OR 0.19, 95% CI 0.05 to 0.57).

21、Use of β-blockers, glycoprotein IIb/IIIa inhibitors, or ACE inhibitors was not associated with risk reduction.,ARMYDA Trial,Among patients undergoing elective PCI, pre-treatment with atorvastatin was associated with a r

22、eduction in markers of myocardial injury post-procedureMechanism may be related to anti-inflammatory effect of statins,國(guó)內(nèi)研究,68例血脂正常ACS患者被隨機(jī)分為常規(guī)治療組（34例，僅常規(guī)治療），和辛伐他汀組（34例，常規(guī)治療基礎(chǔ)上加用辛伐他汀20mg/d），療程6個(gè)月。于治療前、后8周檢測(cè)血漿BNP、hs

23、CRP水平。所有患者每3個(gè)月隨訪一次，平均隨訪觀察6個(gè)月，以住院或觀察期間的心血管事件為終點(diǎn)。,,,結(jié)論,血脂正常的ACS患者，早期應(yīng)用辛伐他汀干預(yù)可以顯著降低血漿BNP、hs-CRP水平，減輕炎癥反應(yīng)，穩(wěn)定動(dòng)脈粥樣硬化斑塊減少心血管管事件發(fā)生。,翁根龍.心血管康復(fù)醫(yī)學(xué)雜志，2019，21(1):70-72,國(guó)內(nèi)研究,52例ACS患者隨機(jī)分成3組，A組（常規(guī)治療）；B組：辛伐他汀20 mg/ d，C組：辛伐他汀40mg/d

24、，隨訪觀察3組患者首次入院后1個(gè)月和1年的終點(diǎn)事件發(fā)生率(死亡、再發(fā)心絞痛或心肌梗死、再入院率)以及血脂水平、肝腎功能和不良反應(yīng)結(jié)果。,TC≥4.68mmol/LLDL-C≥2.6mmol/LTG≥1.7mmol/LHDL-C＜1.0mmol/L,研究前病人的血脂狀態(tài),結(jié)果,,結(jié)論,辛伐他汀20、40 mg用于ACS早期治療均安全有效均能有效降低近期冠心病事件發(fā)生率和病死率，且提示療效與劑量成正相關(guān)。,熊全庚,范木林,郭