Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, UK.
Trends Cardiovasc Med. 2018 Jul;28(5):348-354. doi: 10.1016/j.tcm.2017.12.011. Epub 2017 Dec 28.
Epidemiology and the results of large-scale outcome trials indicate that the association of LDL with atherosclerotic cardiovascular disease is causal, and continuous not only across levels seen in the general population but also down to sub-physiological values. There is no scientific basis, therefore, to set a target or 'floor' for LDL cholesterol lowering, and this presents a clinical and conceptual dilemma for prescribers, patients, and payers. With the advent of powerful agents such as proprotein convertase/subtilisin kexin type 9 (PCSK9) inhibitors, LDL cholesterol can be lowered profoundly but health economic constraints mandate that this therapeutic approach needs to be selective. Based on the need to maximize the absolute risk reduction when prescribing combination lipid-lowering therapy, it is appropriate to prioritize patients with the highest risk (aggressive and established CVD) who will obtain the highest benefit, that is, those with elevated LDL cholesterol on optimized statin therapy.
流行病学和大规模结局试验的结果表明，LDL 与动脉粥样硬化性心血管疾病的关联是因果关系，不仅贯穿于一般人群中所见的水平，而且还延伸到亚生理值。因此，没有科学依据为 LDL 胆固醇降低设定目标或“下限”，这给开处方者、患者和支付者带来了临床和概念上的困境。随着前蛋白转化酶枯草溶菌素 9（PCSK9）抑制剂等强效药物的出现，LDL 胆固醇可以被显著降低，但健康经济学的限制要求这种治疗方法需要具有选择性。基于在开处方联合降脂治疗时最大化绝对风险降低的需要，优先考虑风险最高的患者（积极且已确诊的 CVD）是合适的，这些患者将获得最大的益处，即那些在优化他汀类药物治疗后 LDL 胆固醇升高的患者。
