急性冠脈綜合癥的降脂治療

Lipid-loweringtreatmentofacutecoronarysyndromeContents概述1ACS與血脂關(guān)系2降脂治療對(duì)ACS臨床益處3ACS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),2013,12:150-153ACS

血脂

關(guān)系A(chǔ)CS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)用他汀類藥物進(jìn)行強(qiáng)化降脂治療。趙水平.中華心血管病雜志,2013,41(7):

542-543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),2011,11:1476-1478ACS與血脂狀態(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),2010年,學(xué)位論文ACS降脂治療臨床益處Effects

of

atorvastatin

on

early

recurrentischemiceventsinacutecoronarysyndromes:theMIRACLstudy:arandomizedcontrolledtrial.★Arandomized,double-blindtrial★1997.5to1999.9★follow-up16weeks★122clinicalcentersinEurope,NorthAmerica,SouthAfrica,andAustralasia.★Atotalof3086adultsaged18yearsorolderwithunstableanginaornon-Q-waveacutemyocardialinfarction.★①Todeterminewhethertreatmentwith

atorvastatin

②80mg/datorvastatin,initiated24to96hoursafteranacutecoronarysyndromeRulstConclusion

Forpatientswithacutecoronarysyndrome,lipid-loweringtherapywithatorvastatin,80mg/d,reducesrecurrentischemiceventsinthefirst16weeks,mostlyrecurrentsymptomaticischemiarequiringrehospitalization.SchwartzGG，etal.JAMA.

2001

Apr4;285(13):1711-8.AtoZ(theAggrastattoZocor）Time:

December29,1999,andJanuary6,2003Design:

①patients(n=2265)withACSreceiving40mg/dofsimvastatinfor1monthfollowedby80mg/d

②patients(n=2232)withACSpatientsreceivingplacebofor4monthsfollowedby20mg/dofsimvastatinFollow-up:6～24months.Theprimaryendpoint:

CardiovasculardeathNonfatalmyocardialinfarctionReadmissionforACSStrokeAmongpatientswithACS,theearlyinitiationofanaggressivesimvastatinregimenresultedinafavorabletrendtowardreductionofmajorcardiovascularevents.Conclusions

ARMYDATrialPasceriV,etalCirculation2004;110:674-8AtorvastatinforReductionofMyocardialDamageDuringAngioplasty153patientsscheduledforelectivePCIirrespectiveofbaselinelipidlevelsRandomized,double-blindAtorvastatin40mg/dn=76Placebon=77EndPoints★Theprimaryendpoint：occurrenceofmyocardialinfarction（CK-MB>2times）★Secondaryendpoints：①othermarkersofmyocardialinjury（CK-MB,troponinIandmyoglobin）＞uppernormallimits②meanpeakvaluesofCK-MB,troponinIandmyoglobinafterintervention③occuringadversecardiacevents(death,myocardialinfarction,orneedforunplannedrevascularization)WithinamonthARMYDATrial

Primaryendpointofpost-procedureMI(CKMB>2xULN)↓inatorvastatingroupvsplacebo(Figure)Presenceofmarkers>1xULNalso↓inatorvastatinarm:CKMB12%vs35%,p=0.001;troponinI20%vs48%p=0.0004;myoglobin22%vs51%,p=0.0005Circulation2004;110:674-8Post-procedureMI(>2xULN)p=0.025ARMYDATrialCirculation2004;110:674-8

PeakvaluesofCK-MB,troponinI,andmyoglobininstatinvsplacebogroup.Dataaremean±SEM.pretreatmentwithatorvastatinsignificantlyreducedriskofperiproceduralmyocardialinfarction(OR0.19,95%CI0.05to0.57).Useofβ-blockers,glycoproteinIIb/IIIainhibitors,orACEinhibitorswasnotassociatedwithriskreduction.ARMYDATrial

AmongpatientsundergoingelectivePCI,pre-treatmentwithatorvastatinwasassociatedwithareductioninmarkersofmyocardialinjurypost-procedureMechanismmayberelatedtoanti-inflammatoryeffectofstatins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、hsCRP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，2012，21(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20mg/d，C組：辛伐他汀40mg/d，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/L