Van Ganse E, Souchet T, Laforest L, Moulin P, Bertrand M, Le Jeunne P, Travier N, Yin D, Alemao E, de Pouvourville G
Pharmacoepidemiology, EA3091, CHU-Lyon, France.
Br J Clin Pharmacol. 2005 Apr;59(4):456-63. doi: 10.1111/j.1365-2125.2005.02266.x.
Evidence confirms the positive effects of lipid-lowering agents on the risk of cardiovascular disease. Local guidelines in France (AFSSAPS) have defined therapeutic objectives for LDL-cholesterol. These objectives vary with the number of cardiovascular risk factors in addition to dyslipidaemia. We determined the proportions of patients at therapeutic objective in different classes of cardiovascular risk to test the hypothesis that compliance with guidelines varies across the levels of risk. Comparison with international guidelines (ANDEM) was also performed.
A group of 3173 dyslipidaemic patients treated with lipid-lowering agents and managed by general practitioners was randomly selected from BKL-Thales panel, a French computerized database. For each patient, history of coronary heart disease and the number of cardiovascular risk factors were documented. Compliance with guidelines was assessed from achievement of therapeutic objective.
The study population included 79% primary prevention patients (1.6, 25.5, 31.7 and 20.1%, with 1, 2, 3, and >3 risk factors, respectively) and 21.0% secondary prevention patients. Applying AFSSAPS guidelines, the proportions of primary prevention patients not at LDL-cholesterol objectives varied across risk categories (P < 0.0001), from 3.9% for patients with one risk factor to 46.5% for patients with >3 risk factors, and therapeutic failure reached 39.9% in secondary prevention. Only 26% of patients who were at high cardiovascular risk (>3 risk factors or prior coronary heart disease) and not at therapeutic objective received high doses (>standard recommended doses) of lipid-lowering agents in monotherapy. Applying ANDEM guidelines, 74% of secondary prevention patients were not at treatment goal.
Compliance with guidelines varied inversely with the level of cardiovascular risk. Besides, most patients not at therapeutic objective were not up-titrated. The use of lipid-lowering agents is inadequate, depriving many patients of an effective protection against cardiovascular diseases.
有证据证实降脂药物对心血管疾病风险具有积极作用。法国当地指南（AFSSAPS）已明确了低密度脂蛋白胆固醇的治疗目标。这些目标会因除血脂异常外的心血管危险因素数量不同而有所差异。我们确定了不同心血管风险类别中达到治疗目标的患者比例，以检验以下假设：指南的依从性会因风险水平的不同而有所变化。同时还与国际指南（ANDEM）进行了比较。
从法国计算机化数据库BKL - 泰雷兹面板中随机选取一组3173例接受降脂药物治疗且由全科医生管理的血脂异常患者。记录每位患者的冠心病病史和心血管危险因素数量。根据是否达到治疗目标来评估对指南的依从性。
研究人群包括79%的一级预防患者（分别有1、2、3和>3个危险因素的患者比例为1.6%、25.5%、31.7%和20.1%）以及21.0%的二级预防患者。应用AFSSAPS指南，未达到低密度脂蛋白胆固醇目标的一级预防患者比例在不同风险类别中存在差异（P < 0.0001），从有1个危险因素的患者中的3.9%到有>3个危险因素的患者中的46.5%，二级预防中的治疗失败率达到39.9%。在心血管高风险（>3个危险因素或既往有冠心病）且未达到治疗目标的患者中，只有26%的患者接受了单药治疗的高剂量（>标准推荐剂量）降脂药物。应用ANDEM指南时，74%的二级预防患者未达到治疗目标。
对指南的依从性与心血管风险水平呈负相关。此外，大多数未达到治疗目标的患者未接受剂量上调治疗。降脂药物的使用不足，使许多患者无法获得预防心血管疾病的有效保护。
