Bordalo Alvaro Donas-Botto, Nobre Angelo Lucas, Dantas Manuel, Cravino João
Serviço de Cirurgia Cardiotorácica, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal.
Rev Port Cardiol. 2012 Jun;31(6):415-24. doi: 10.1016/j.repc.2011.12.018.
In spite of high prevalences of hypertension and hypercholesterolemia, the majority of elderly patients admitted for aortic valve surgery due to calcific aortic valve disease (CAVD) do not have significant coronary artery disease (CAD).
To evaluate the lipid profile (LP) of patients undergoing surgery for CAVD and to correlate this with coronary angiographic data and prior cardiovascular risk factor profile.
This was a prospective observational cohort study of 264 consecutive patients aged >59 years (mean 72), 126 men (48%) and 138 women (52%). According to the angiographic presence (irregularities, moderate or significant lesions) or absence (normal angiogram) of significant CAD respectively, patients were divided into two groups: A (n=127, 48%) and B (n=137, 52%). A mean of 3.5 classical risk factors were identified in men and 2.6 in women. LP (obtained on admission, in the fasting state) included total cholesterol (TC), HDL, triglycerides (TG), LDL, and lipoprotein(a).
With the exception of male gender, diabetes and HDL, the other factors studied - smoking, hypertension, TC, TG, LDL (in both statin-treated and non-statin-treated patients) and lipoprotein(a) - did not show significant differences between groups A and B; LDL was 116 +/- 40mg/dl in group A vs. 123 +/- 38mg/dl in group B, in non-statin-treated patients; significant CAD was identified in 64% of men vs. 26% of women (p < 0.001); 43% of group A had diabetes vs. 27% of group B (p<0.01); HDL was 49 +/- 14mg/dl in group A vs. 59 +/- 16mg/dl in group B (p < 0.001); HDL in group A was 49 +/- 14 mg/dl in men vs. 49 +/- 13 mg/dl in women (NS) and 45 +/- 13 mg/dl in diabetic patients vs. 52 +/- 14 mg/dl in non-diabetics (p <0.02); HDL in group B diabetic patients was 54 +/- 17 mg/dl in men vs. 56 +/- 18 mg/dl in women (NS), and HDL in group B non-diabetic patients was 55 +/- 13mg/dl in men vs. 63 +/- 17 mg/dl in women (p < 0.02). Multivariate analysis showed that only low HDL and diabetes (in women) were independent risk factors for significant CAD. The effect of male gender as a risk factor appears to be exerted mainly through lower HDL levels.
Elevated HDL is the main negative risk factor for significant CAD in elderly high-risk but mildly dyslipidemic CAVD patients. HDL does not appear to have any protective effect in the pathophysiology of CAVD. In terms of long-term intervention, primary prevention of significant CAD should in the future be hybrid, focusing mainly on improving HDL function, but also on lowering LDL.
尽管高血压和高胆固醇血症的患病率很高，但大多数因钙化性主动脉瓣疾病（CAVD）而接受主动脉瓣手术的老年患者并没有明显的冠状动脉疾病（CAD）。
评估接受CAVD手术患者的血脂谱（LP），并将其与冠状动脉造影数据及既往心血管危险因素谱相关联。
这是一项对264例年龄大于59岁（平均72岁）的连续患者进行的前瞻性观察队列研究，其中男性126例（48%），女性138例（52%）。根据冠状动脉造影是否存在明显CAD（不规则、中度或重度病变）或不存在（正常造影），患者被分为两组：A组（n = 127，48%）和B组（n = 137，52%）。男性平均识别出3.5个经典危险因素，女性为2.6个。LP（入院时在空腹状态下获得）包括总胆固醇（TC）、高密度脂蛋白（HDL）、甘油三酯（TG）、低密度脂蛋白（LDL）和脂蛋白（a）。
除男性、糖尿病和HDL外，其他研究因素——吸烟、高血压、TC、TG、LDL（他汀类治疗和未治疗患者）和脂蛋白（a）——在A组和B组之间没有显著差异；未接受他汀类治疗的患者中，A组LDL为116±40mg/dl，B组为123±38mg/dl；男性中64%被诊断为明显CAD，女性为26%（p<0.001）；A组43%患有糖尿病，B组为27%（p<0.01）；A组HDL为49±14mg/dl，B组为59±16mg/dl（p<0.001）；A组男性HDL为49±14mg/dl，女性为49±13mg/dl（无显著差异），糖尿病患者为45±13mg/dl，非糖尿病患者为52±14mg/dl（p<0.02）；B组糖尿病男性患者HDL为54±17mg/dl，女性为56±18mg/dl（无显著差异），B组非糖尿病男性患者HDL为55±13mg/dl，女性为63±17mg/dl（p<0.02）。多因素分析显示，只有低HDL和糖尿病（女性）是明显CAD的独立危险因素。男性作为危险因素的作用似乎主要通过较低的HDL水平发挥。
HDL升高是老年高危但轻度血脂异常的CAVD患者明显CAD的主要负性危险因素。HDL在CAVD的病理生理学中似乎没有任何保护作用。就长期干预而言，未来明显CAD的一级预防应是综合性的，主要侧重于改善HDL功能，但也要降低LDL。
