Woloshin Steven, Schwartz Lisa M, Kerin Kevin, Welch H Gilbert
VA Outcomes Group, White River Junction, VT, USA.
J Gen Intern Med. 2007 Feb;22(2):197-204. doi: 10.1007/s11606-006-0033-z.
There is growing interest in using C-reactive protein (CRP) levels to help select patients for lipid lowering therapy--although this practice is not yet supported by evidence of benefit in a randomized trial.
To estimate the number of Americans potentially affected if a CRP criteria were adopted as an additional indication for lipid lowering therapy. To provide context, we also determined how well current lipid lowering guidelines are being implemented.
We analyzed nationally representative data to determine how many Americans age 35 and older meet current National Cholesterol Education Program (NCEP) treatment criteria (a combination of risk factors and their Framingham risk score). We then determined how many of the remaining individuals would meet criteria for treatment using 2 different CRP-based strategies: (1) narrow: treat individuals at intermediate risk (i.e., 2 or more risk factors and an estimated 10-20% risk of coronary artery disease over the next 10 years) with CRP > 3 mg/L and (2) broad: treat all individuals with CRP > 3 mg/L.
Analyses are based on the 2,778 individuals participating in the 1999-2002 National Health and Nutrition Examination Survey with complete data on cardiac risk factors, fasting lipid levels, CRP, and use of lipid lowering agents.
The estimated number and proportion of American adults meeting NCEP criteria who take lipid-lowering drugs, and the additional number who would be eligible based on CRP testing.
About 53 of the 153 million Americans aged 35 and older meet current NCEP criteria (that do not involve CRP) for lipid-lowering treatment. Sixty-five percent, however, are not currently being treated, even among those at highest risk (i.e., patients with established heart disease or its risk equivalent)-62% are untreated. Adopting the narrow and broad CRP strategies would make an additional 2.1 and 25.3 million Americans eligible for treatment, respectively. The latter strategy would make over half the adults age 35 and older eligible for lipid-lowering therapy, with most of the additionally eligible (57%) coming from the lowest NCEP heart risk category (i.e., 0-1 risk factors).
There is substantial underuse of lipid lowering therapy for American adults at high risk for coronary disease. Rather than adopting CRP-based strategies, which would make millions more lower risk patients eligible for treatment (and for whom treatment benefit has not yet been demonstrated in a randomized trial), we should ensure the treatment of currently defined high-risk patients for whom the benefit of therapy is established.
使用C反应蛋白（CRP）水平来帮助选择降脂治疗患者的兴趣日益浓厚——尽管这一做法尚未得到随机试验中获益证据的支持。
估计如果将CRP标准作为降脂治疗的额外指征，可能受影响的美国人数。为提供背景信息，我们还确定了当前降脂指南的实施情况。
我们分析了具有全国代表性的数据，以确定35岁及以上的美国成年人中有多少人符合当前国家胆固醇教育计划（NCEP）的治疗标准（风险因素及其弗雷明汉风险评分的组合）。然后，我们确定了其余个体中有多少人将符合使用2种不同的基于CRP的策略进行治疗的标准：（1）狭义：治疗中度风险个体（即有2个或更多风险因素且预计未来10年患冠状动脉疾病的风险为10 - 20%）且CRP > 3mg/L的个体；（2）广义：治疗所有CRP > 3mg/L的个体。
分析基于1999 - 2002年全国健康和营养检查调查中参与的2778名个体，这些个体具有关于心脏风险因素、空腹血脂水平、CRP和降脂药物使用的完整数据。
符合NCEP标准且服用降脂药物的美国成年人的估计数量和比例，以及基于CRP检测将符合治疗条件的额外人数。
在1.53亿35岁及以上的美国人中，约53人符合当前NCEP（不涉及CRP）的降脂治疗标准。然而，即使在风险最高的人群（即已确诊心脏病或其风险等同情况的患者）中，65%的人目前未接受治疗——62%未接受治疗。采用狭义和广义的CRP策略将分别使另外210万和2530万美国人有资格接受治疗。后一种策略将使超过一半的35岁及以上成年人有资格接受降脂治疗，其中大多数额外符合条件的人（57%）来自NCEP心脏风险最低类别（即0 - 1个风险因素）。
对于患冠状动脉疾病高风险的美国成年人，降脂治疗的使用严重不足。我们不应采用基于CRP的策略，因为这将使数百万风险较低的患者有资格接受治疗（且在随机试验中尚未证明治疗对其有益），而应确保对目前已确定的、治疗获益已得到证实的高风险患者进行治疗。
