Stejfa M
I. interní kardioangiologická klinika LF MU a FN U sv. Anny, Brno.
Vnitr Lek. 2000 Sep;46(9):520-5.
Eccentric atherogenic plaques which cause only insignificant narrowing of the diameter of coronary arteries are the cause of 60-80% of all acute coronary syndromes. The plaque becomes unstable (vulnerable) due to cytokines released by macrophages in the lipid rich core. Weakening of the fibrous capsule of the core then leads to rupture of the plaque and subsequently to intracoronary thrombosis with a wide spectrum of ischaemia or even necrosis of the myocardium. Secondary preventive studies (4S, LIPID, CARE), morphological non-mortality studies (e.g. AVERT, REGRESS, LCAS) and primary preventive studies (WOSCOPS, AFCAPS/TexCAPS) revealed that statins reduce significantly, as compared with placebo, total and LDL-cholesterol by 20-35% and lead in subsequent years to a significant decline of the relative risk of the general and coronary mortality and morbidiy by 20-40%. They prevent progression and may lead to regression of coronary sclerosis. They do not act by mere reduction of the cholesterol level but also by their extralipid effects which stabilize the plaque. 80% of patients with coronary syndrome have cholesterol levels between 6.0 and 7.5 mmol/l, similarly as ca 40% of healthy middle aged persons. The difference is in the risk caused either by the presence of ischaemic heart disease or in healthy subjects by the cumulation of several coronary risk factors. A special risk group are the remaining 20% patients. They include subjects with a cholesterol level above 8 mmol/l who must be treated more aggressively, similarly as patients after a venous aortocoronary bypass. Subjects with slightly elevated LDL-cholesterol values but high triacylglycerol levels and lower HDL-cholesterol levels have also an atherogenic risk. This applies not only to postmenopausal women, elderly people, obese and diabetic subjects, hypertensive subjects with insulin resistance but also to young subjects. In the latter reduction of triacylglycerols is indicated. In coronary patients a combination of statins and fibrates may be used. Basic hypolipidaemic treatment for reduction of the atherothrombotic risk are statins. Despite statin treatment the prospective mortality and morbidity of coronary patients is still high and it is necessary to make an effort to achieve target lipid levels. Recent studies provide new findings, further progress and stricter therapy are foreseen.
仅导致冠状动脉直径轻度狭窄的偏心性动脉粥样硬化斑块是所有急性冠状动脉综合征60% - 80%的病因。由于富含脂质核心中的巨噬细胞释放细胞因子，斑块变得不稳定（易损）。核心纤维帽的削弱随后导致斑块破裂，进而导致冠状动脉内血栓形成，并伴有广泛的心肌缺血甚至坏死。二级预防研究（4S、LIPID、CARE）、形态学非死亡率研究（如AVERT、REGRESS、LCAS）和一级预防研究（WOSCOPS、AFCAPS/TexCAPS）表明，与安慰剂相比，他汀类药物可使总胆固醇和低密度脂蛋白胆固醇显著降低20% - 35%，并在随后几年使总体和冠状动脉死亡率及发病率的相对风险显著下降20% - 40%。它们可防止冠状动脉硬化进展，并可能使其逆转。它们不仅通过降低胆固醇水平起作用，还通过其稳定斑块的非脂质效应发挥作用。80%的冠状动脉综合征患者胆固醇水平在6.0至7.5 mmol/l之间，同样约40%的健康中年人也是如此。区别在于缺血性心脏病的存在所导致的风险，或健康受试者中多种冠状动脉危险因素的累积所导致的风险。其余20%的患者是一个特殊的风险群体。他们包括胆固醇水平高于8 mmol/l的受试者，这些受试者必须接受更积极的治疗，就像接受静脉主动脉冠状动脉搭桥术后的患者一样。低密度脂蛋白胆固醇值略有升高但甘油三酯水平高且高密度脂蛋白胆固醇水平低的受试者也有动脉粥样硬化风险。这不仅适用于绝经后女性、老年人、肥胖和糖尿病患者、有胰岛素抵抗的高血压患者，也适用于年轻受试者。对于后者，建议降低甘油三酯水平。在冠状动脉疾病患者中，可联合使用他汀类药物和贝特类药物。降低动脉粥样硬化血栓形成风险的基本降脂治疗是他汀类药物。尽管进行了他汀类药物治疗，冠状动脉疾病患者的预期死亡率和发病率仍然很高，因此有必要努力达到目标血脂水平。最近的研究提供了新的发现，预计将取得进一步进展并采用更严格的治疗方法。
