Gitt Anselm K, Juenger Claus, Jannowitz Christina, Karmann Barbara, Senges Juergen, Bestehorn Kurt
Institut für Herzinfarktforschung Ludwigshafen an der Universität Heidelberg, Ludwigshafen, Germany.
Eur J Cardiovasc Prev Rehabil. 2009 Aug;16(4):438-44. doi: 10.1097/HJR.0b013e32832a4e25.
Lipid-lowering treatment has been proven to decrease the rate of cardiovascular events in high-risk patients with manifest coronary artery disease (CAD) or CAD equivalent risk profile. Current treatment guidelines recommend low-density lipoprotein-cholesterol (LDL-C) less than 100 mg/dl (optional <70 mg/dl) as the target level for this high-risk population. Little is known about the ambulatory treatment of high-risk patients in clinical practice and the achievement of guideline recommended target values.
In the '2L cardio' registry in Germany, 295 cardiologists enrolled 6711 consecutive patients with known CAD, and/or diabetes mellitus, peripheral arterial disease (summarized as 'coronary risk equivalent', CE), on chronic statin treatment. They recorded actual LDL-C values at entry, probable changes in therapy, and the expected LDL-C values using a lipid calculator based on an earlier observational study in a similar setting. The three groups comprised 2618 patients with CAD plus CE (39.0%; median LDL-C 112 mg/dl), 3436 patients with CAD only (51.2%; median LDL-C 108 mg/dl), and 657 with CE only (9.8%; median LDL-C 124 mg/dl). They had LDL-C levels less than 100 mg/dl in 36.2% [95% confidence intervals (CI): 34.3-38.1], 39.7% (CI: 38.0-41.4), and 27.2% (CI: 23.7-30.7), respectively. Statin doses at entry were usually in the lower to intermediate range (e.g. simvastatin median 25 mg/day). Cardiologists switched to another statin in 10.1% (9.4-10.8), increased the dose of statins (if same drug) in 22.2% (CI: 21.1-23.2) and/or added a cholesterol absorption inhibitor in 23.7% (CI: 22.7-24.7) of the patients. The cardiologists' intervention improved expected LDL-C levels in the total cohort by a mean of 9.0 mg/dl, but the 100 mg/dl LDL-C target was only reached in 51.3% (CI: 50.0-52.5) of the total cohort. CE patients appeared undertreated in terms of antiplatelet drugs.
Through infrequent increases in statin doses and mainly through add-on of a cholesterol absorption inhibitor, cardiologists improved target level attainment. Compared with earlier studies in the outpatient setting, the treatment to target for LDL-C of high-risk CAD patients has improved, but is not satisfactory.
降脂治疗已被证明可降低患有明显冠状动脉疾病（CAD）或具有CAD等效风险特征的高危患者的心血管事件发生率。当前治疗指南推荐将低密度脂蛋白胆固醇（LDL-C）低于100mg/dl（可选<70mg/dl）作为该高危人群的目标水平。关于临床实践中高危患者的门诊治疗以及指南推荐目标值的达成情况，人们了解甚少。
在德国的“2L心脏”注册研究中，295名心脏病专家纳入了6711例连续接受慢性他汀类药物治疗的已知CAD患者和/或糖尿病、外周动脉疾病患者（总结为“冠状动脉风险等效物”，CE）。他们记录了入组时的实际LDL-C值、可能的治疗变化，以及使用基于早期在类似环境中的观察性研究的脂质计算器得出的预期LDL-C值。三组分别包括2618例CAD加CE患者（39.0%；LDL-C中位数112mg/dl）、3436例仅患有CAD的患者（51.2%；LDL-C中位数108mg/dl）和657例仅患有CE的患者（9.8%；LDL-C中位数124mg/dl）。他们的LDL-C水平分别在36.2%[95%置信区间（CI）：34.3 - 38.1]、39.7%（CI：38.0 - 41.4）和27.2%（CI：23.7 - 30.7）的患者中低于100mg/dl。入组时他汀类药物剂量通常处于低至中等范围（例如辛伐他汀中位数为25mg/天）。心脏病专家在10.1%（9.4 - 10.8）的患者中换用了另一种他汀类药物，在22.2%（CI：21.1 - 23.2）的患者中增加了他汀类药物剂量（如果是同一种药物），和/或在23.7%（CI：22.7 - 24.7）的患者中添加了胆固醇吸收抑制剂。心脏病专家的干预使整个队列的预期LDL-C水平平均提高了9.0mg/dl，但仅在51.3%（CI：50.0 - 52.5）的整个队列中达到了100mg/dl的LDL-C目标。在抗血小板药物方面，CE患者似乎治疗不足。
通过不频繁增加他汀类药物剂量且主要通过添加胆固醇吸收抑制剂，心脏病专家提高了目标水平的达成率。与早期门诊环境中的研究相比，高危CAD患者LDL-C的达标治疗有所改善，但仍不尽人意。
