Einstein Medical Center Philadelphia, Philadelphia, Pennsylvania.
J Am Coll Cardiol. 2013 Nov 12;62(20):1826-33. doi: 10.1016/j.jacc.2013.07.051. Epub 2013 Aug 21.
This study sought to assess the independent effect of high-density lipoprotein-cholesterol (HDL-C) level on cardiovascular risk in patients with stable ischemic heart disease (SIHD) who were receiving optimal medical therapy (OMT).
Although low HDL-C level is a powerful and independent predictor of cardiovascular risk, recent data suggest that this may not apply when low-density lipoprotein-cholesterol (LDL-C) is reduced to optimal levels using intensive statin therapy.
We performed a post-hoc analysis in 2,193 men and women with SIHD from the COURAGE trial. The primary outcome measure was the composite of death from any cause or nonfatal myocardial infarction (MI). The independent association between HDL-C levels measured after 6 months on OMT and the rate of cardiovascular events after 4 years was assessed. Similar analyses were performed separately in subjects with LDL-C levels below 70 mg/dl (1.8 mmol/l).
In the overall population, the rate of death/MI was 33% lower in the highest HDL-C quartile as compared with the lowest quartile, with quartile of HDL-C being a significant, independent predictor of death/MI (p = 0.05), but with no interaction for LDL-C category (p = 0.40). Among subjects with LDL-C levels <70 mg/dl, those in the highest quintile of HDL-C had a 65% relative risk reduction in death or MI as compared with the lowest quintile, with HDL-C quintile demonstrating a significant, inverse predictive effect (p = 0.02).
In this post-hoc analysis, patients with SIHD continued to experience incremental cardiovascular risk associated with low HDL-C levels despite OMT during long-term follow-up. This relationship persisted and appeared more prominent even when LDL-C was reduced to optimal levels with intensive dyslipidemic therapy. (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation; NCT00007657).
本研究旨在评估在接受最佳药物治疗（OMT）的稳定型缺血性心脏病（SIHD）患者中，高密度脂蛋白胆固醇（HDL-C）水平对心血管风险的独立影响。
尽管低 HDL-C 水平是心血管风险的有力且独立的预测因素，但最近的数据表明，当使用强化他汀类药物治疗将 LDL-C 降低到最佳水平时，这种情况可能并不适用。
我们对 COURAGE 试验中的 2193 名男性和女性 SIHD 患者进行了事后分析。主要终点是任何原因导致的死亡或非致死性心肌梗死（MI）的复合事件。评估在 OMT 治疗 6 个月后测量的 HDL-C 水平与 4 年后心血管事件发生率之间的独立关联。在 LDL-C 水平低于 70mg/dl（1.8mmol/l）的患者中分别进行了类似的分析。
在总体人群中，最高 HDL-C 四分位组的死亡/MI 发生率比最低四分位组低 33%，HDL-C 四分位组是死亡/MI 的显著独立预测因素（p=0.05），但 LDL-C 类别无交互作用（p=0.40）。在 LDL-C 水平<70mg/dl 的患者中，最高五分位组的死亡或 MI 风险相对降低 65%，与最低五分位组相比，HDL-C 五分位组显示出显著的反向预测效应（p=0.02）。
在这项事后分析中，即使在长期随访中接受 OMT，SIHD 患者仍会因低 HDL-C 水平而持续面临额外的心血管风险。这种关系持续存在，甚至在 LDL-C 被强化降脂治疗降低到最佳水平时，这种关系似乎更为明显。（利用血管重建和强化药物评估的临床结果；NCT00007657）。
