Department of Endocrinology and Metabolism, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France.
Department of Cardiology, Toulouse Rangueil University Hospital, 1, avenue du Professeur-Jean-Poulhès, TSA 50032, 31059 Toulouse cedex 9, France.
Arch Cardiovasc Dis. 2014 Mar;107(3):188-200. doi: 10.1016/j.acvd.2014.01.011. Epub 2014 Mar 7.
The use of pharmacological lipid-lowering intervention in individuals with hypercholesterolaemia and known cardiovascular disease or diabetes/chronic kidney disease is well established. Current European Society of Cardiology guidelines recommend immediate initiation of drugs in adjunct to lifestyle intervention in these patients at high or very high cardiovascular risk. In these clinical settings, statins are generally chosen as the first-choice drug intervention, in consideration of the robust evidence showing a reduction in all-cause mortality and major adverse cardiac events (MACE). In contrast, primary prevention with statins, even in the subset of patients at high-risk of cardiovascular events, is not well implemented. This might be related to a lack of public awareness regarding the actual risk associated with prolonged exposure to high concentrations of low-density lipoprotein cholesterol (LDL-C) and uncertainties in the clinical evidence coming from the earliest trials in this patient subset. However, recent observational studies suggest that lowering LDL-C earlier in life and for a longer duration can substantially decrease the burden of cardiovascular disease and mortality. Moreover, results from recent well-conducted large meta-analyses of randomized clinical trials showed that primary prevention with statins reduced all-cause mortality by 14% and MACE by > 20% - findings similar to those observed for the use of statins in secondary prevention. Recently published American Heart Association/American College of Cardiology guidelines on the treatment of blood cholesterol emphasize that primary prevention using high-dose statins in individuals with LDL-C ≥ 190 mg/dL induces a benefit in atherosclerotic cardiovascular risk reduction that clearly exceeds the potential for adverse effects. We aim in this review to discuss the new data that advocate the use of statins in primary prevention earlier and more frequently, putting the efficacy evidence into perspective with new insights in terms of safety issues.
在高胆固醇血症且患有已知心血管疾病或糖尿病/慢性肾脏病的个体中，使用药理学降脂干预措施已得到充分证实。目前，欧洲心脏病学会指南建议，在这些具有高或极高心血管风险的患者中，除生活方式干预外，应立即联合使用药物。在这些临床情况下，通常选择他汀类药物作为首选药物干预，这是考虑到强有力的证据表明可降低全因死亡率和主要不良心脏事件（MACE）。相比之下，他汀类药物的一级预防，即使在心血管事件风险高的亚组患者中，也没有得到很好的实施。这可能与公众对长期暴露于高浓度低密度脂蛋白胆固醇（LDL-C）相关实际风险的认识不足以及该患者亚组最早试验的临床证据存在不确定性有关。然而，最近的观察性研究表明，更早且更长期地降低 LDL-C 可以显著降低心血管疾病和死亡率的负担。此外，最近进行的大型他汀类药物随机临床试验荟萃分析的结果表明，他汀类药物的一级预防可使全因死亡率降低 14%，MACE 降低>20%，这与二级预防中观察到的他汀类药物使用效果相似。最近发布的美国心脏协会/美国心脏病学会关于治疗血胆固醇的指南强调，在 LDL-C≥190mg/dL 的个体中使用高剂量他汀类药物进行一级预防可降低动脉粥样硬化性心血管风险，其益处明显超过潜在的不良反应。我们旨在通过本综述讨论支持更早、更频繁地在一级预防中使用他汀类药物的新数据，并从安全性问题的新角度来看待疗效证据。
