急性冠状动脉综合征中高胆固醇血症与死亡率的矛盾关系
Hypercholesterolemia paradox in relation to mortality in acute coronary syndrome.
作者信息
Wang Tracy Y, Newby L Kristin, Chen Anita Y, Mulgund Jyotsna, Roe Matthew T, Sonel Ali F, Bhatt Deepak L, DeLong Elizabeth R, Ohman E Magnus, Gibler W Brian, Peterson Eric D
机构信息
Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina 27705, USA.
出版信息
Clin Cardiol. 2009 Sep;32(9):E22-8. doi: 10.1002/clc.20518.
BACKGROUND
Hypercholesterolemia is a risk factor for coronary artery disease, yet is associated with lower risk of adverse outcomes in patients with acute coronary syndromes (ACS).
HYPOTHESIS
We explored this paradox in 84,429 patients with non-ST-segment elevation ACS in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines registry.
METHODS
We examined the association between a history of hypercholesterolemia and in-hospital mortality after adjusting for clinical covariates. After excluding patients with previously diagnosed hypercholesterolemia, we repeated the analysis, examining the association between newly diagnosed hypercholesterolemia (in-hospital low-density lipoprotein cholesterol [LDL-C] > or = 100 mg/dL) and mortality.
RESULTS
A history of hypercholesterolemia was associated with lower in-hospital mortality (unadjusted odds ratio [OR]: 0.58; 95% confidence interval [CI]: 0.55, 0.62). This protective association persisted after adjusting for baseline characteristics (OR: 0.71; 95% CI: 0.66, 0.76) and prior statin use (OR: 0.74; 95% CI: 0.68, 0.80). Among 22,711 patients with no history of hypercholesterolemia, 12,809 had a new in-hospital diagnosis of hypercholesterolemia. Unadjusted mortality in these patients was lower than among those with normal LDL levels (OR: 0.58; 95% CI: 0.50, 0.67); however, this difference was not significant after multivariable adjustment (OR: 0.86; 95% CI: 0.73, 1.01).
CONCLUSIONS
The association of hypercholesterolemia with better outcomes highlights a major challenge in observational analyses. Our results suggest this paradox may result from confounding due to other clinical characteristics, impact of statin treatment, and perhaps most importantly, the fact that previously diagnosed hypercholesterolemia is a marker for patients with more prior medical contact.
背景
高胆固醇血症是冠状动脉疾病的一个危险因素，但在急性冠状动脉综合征（ACS）患者中却与较低的不良结局风险相关。
假设
我们在“能否通过早期实施美国心脏病学会/美国心脏协会指南快速对不稳定型心绞痛患者进行危险分层以抑制不良结局”注册研究中的84429例非ST段抬高型ACS患者中探讨了这一矛盾现象。
方法
在对临床协变量进行校正后，我们研究了高胆固醇血症病史与住院死亡率之间的关联。在排除先前诊断为高胆固醇血症的患者后，我们重复了该分析，研究新诊断的高胆固醇血症（住院期间低密度脂蛋白胆固醇[LDL-C]≥100mg/dL）与死亡率之间的关联。
结果
高胆固醇血症病史与较低的住院死亡率相关（未校正优势比[OR]：0.58；95%置信区间[CI]：0.55，0.62）。在对基线特征（OR：0.71；95%CI：0.66，0.76）和先前他汀类药物使用情况（OR：0.74；95%CI：0.68，0.80）进行校正后，这种保护性关联仍然存在。在22711例无高胆固醇血症病史的患者中，12809例在住院期间新诊断为高胆固醇血症。这些患者未校正的死亡率低于LDL水平正常的患者（OR：0.58；95%CI：0.50，0.67）；然而，在多变量校正后，这种差异并不显著（OR：0.86；95%CI：0.73，1.01）。
结论
高胆固醇血症与较好结局之间的关联凸显了观察性分析中的一个重大挑战。我们的结果表明，这一矛盾现象可能是由于其他临床特征的混杂、他汀类药物治疗的影响，或许最重要的是，先前诊断的高胆固醇血症是患者有更多既往医疗接触史的一个标志。
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