Maroo Bijesh P, Lavie Carl J, Milani Richard V
Ochsner Heart & Vascular Institute, Ochsner Medical Center, New Orleans, Louisiana, USA.
Drugs Aging. 2008;25(8):649-64. doi: 10.2165/00002512-200825080-00003.
Cardiovascular disease remains the leading cause of mortality in elderly patients. While coronary heart disease (CHD) morbidity and mortality have decreased over the last 25 years, the percentage reduction in elderly patients is nearly 50% lower than that for the general adult population. Therefore, aggressive primary and secondary prevention of CHD is imperative for our society, and hyperlipidaemia remains the major modifiable risk factor in the elderly population. However, there appears to be a reluctance among practitioners to treat hyperlipidaemia in elderly patients, a bias that is particularly important given the absolute benefits of treating such patients. While many of the major clinical trials involving HMG-CoA reductase inhibitors (statins) in patients with CHD focused on younger individuals, subsequent subgroup analyses of elderly patients have shown consistent reductions in all-cause mortality, major CHD events and numbers of revascularization procedures. Intensive statin therapy in the setting of acute myocardial infarction (MI) has also been shown to reduce the risk of death, MI, unstable angina, revascularization and stroke in elderly patients. Furthermore, three recent articles that have evaluated intensive lipid-lowering in the elderly population have extended the known benefits of such therapy to elderly patients with acute coronary syndrome and stable CHD.Elderly patients often take multiple medications and are at significant risk of drug-drug interactions. Several available statin medications are metabolized by cytochrome P450 (CYP) 3A4 and can therefore interact with commonly used medications such as amiodarone, macrolide antibacterials, calcium channel antagonists, fibric acid derivatives and ciclosporin. These interactions can result in an increased frequency of statin-related hepatotoxicity and myopathy.There are currently six commercially available statin medications on the US market, three of which, lovastatin, simvastatin and pravastatin, are available in generic formulations, and are thus less expensive. Of the commercially available statins, rosuvastatin, atorvastatin and simvastatin have the highest potency. While rosuvastatin currently lacks clinical event data, atorvastatin has the most clinical event data for CHD and even stroke prevention. Although pravastatin has lower potency than other described statins, it also has the lowest risk of drug-drug interactions involving CYP.
心血管疾病仍然是老年患者死亡的主要原因。虽然在过去25年中冠心病（CHD）的发病率和死亡率有所下降，但老年患者的下降百分比比一般成年人群低近50%。因此，积极开展冠心病的一级和二级预防对我们的社会至关重要，高脂血症仍然是老年人群中主要的可改变危险因素。然而，从业者似乎不愿意治疗老年患者的高脂血症，鉴于治疗这类患者的绝对益处，这种偏见尤为重要。虽然许多涉及HMG-CoA还原酶抑制剂（他汀类药物）治疗冠心病患者的主要临床试验集中在较年轻个体，但随后对老年患者的亚组分析显示，全因死亡率、主要冠心病事件和血运重建手术数量持续下降。在急性心肌梗死（MI）情况下进行强化他汀类药物治疗也已证明可降低老年患者的死亡、MI、不稳定型心绞痛、血运重建和中风风险。此外，最近三篇评估老年人群强化降脂治疗的文章将这种治疗的已知益处扩展到了患有急性冠状动脉综合征和稳定型冠心病的老年患者。老年患者通常服用多种药物，存在显著的药物相互作用风险。几种可用的他汀类药物由细胞色素P450（CYP）3A4代谢，因此可能与常用药物如胺碘酮、大环内酯类抗菌药物、钙通道拮抗剂、纤维酸衍生物和环孢素相互作用。这些相互作用可能导致他汀类药物相关肝毒性和肌病的发生频率增加。目前美国市场上有六种可商购的他汀类药物，其中三种，洛伐他汀、辛伐他汀和普伐他汀有通用剂型，因此价格较低。在可商购的他汀类药物中，瑞舒伐他汀、阿托伐他汀和辛伐他汀效力最高。虽然瑞舒伐他汀目前缺乏临床事件数据，但阿托伐他汀在冠心病甚至中风预防方面有最多的临床事件数据。虽然普伐他汀的效力低于其他所述他汀类药物，但它发生涉及CYP的药物相互作用的风险也最低。
