From the Department of Primary Care and Public Health, Imperial College, London, United Kingdom.
Circ Res. 2019 Feb;124(3):354-363. doi: 10.1161/CIRCRESAHA.118.313245.
Cardiovascular disease (CVD) remains the leading cause of death worldwide. To date, decades of research has established LDL-C (low-density lipoprotein cholesterol) as a causal factor in the development of atherosclerotic CVD. Statin therapy, supported by a broad evidence base, has demonstrated its superior efficacy in reducing LDL-C and subsequent cardiovascular risk. It therefore currently forms the mainstay of lipid-lowering therapy as recommended by international guidelines. Statin therapy is indicated in the secondary prevention of atherosclerotic CVD, as well as genetic causes of dyslipidemia (such as familial hypercholesterolemia). Although this strategy targets those most at risk, it merely addresses those most susceptible and does not account for the fact that most cardiovascular events occur in those at moderate to low risk. In addition, there is evidence for use in primary prevention such as in those with diabetes mellitus, chronic kidney disease, and high risk of future atherosclerotic CVD as determined by risk prediction calculators. Risk prediction tools, however, are far from perfect and do not accurately account for those at low short-term but high lifelong risk. Considering the log-linear relationship between LDL-C reductions and reductions in risk of atherosclerotic CVD, even in those at very low risk of future events, a clinical question posed is can we and should we shift the entire risk distribution by treating everyone? The present review discusses these issues in more detail outlining arguments for and against each approach.
心血管疾病（CVD）仍然是全球范围内的主要死亡原因。迄今为止，数十年的研究已经确定 LDL-C（低密度脂蛋白胆固醇）是动脉粥样硬化性 CVD 发展的一个因果因素。他汀类药物治疗得到了广泛证据的支持，已证明其在降低 LDL-C 和随后降低心血管风险方面的优越性。因此，它目前构成了国际指南推荐的降脂治疗的主要方法。他汀类药物治疗适用于动脉粥样硬化性 CVD 的二级预防，以及脂质代谢异常的遗传原因（如家族性高胆固醇血症）。尽管这种策略针对的是风险最高的人群，但它只是针对那些最易受影响的人群，并没有考虑到大多数心血管事件发生在中低风险人群中的事实。此外，有证据表明，在一级预防中也可以使用他汀类药物，例如在糖尿病、慢性肾脏病和未来发生动脉粥样硬化性 CVD 风险高的人群中，可以使用风险预测计算器。然而，风险预测工具远非完美，无法准确评估那些短期风险低但终身风险高的人群。考虑到 LDL-C 降低与动脉粥样硬化性 CVD 风险降低之间的对数线性关系，即使在未来发生事件的风险非常低的情况下，提出的一个临床问题是，我们能否以及是否应该通过治疗所有人来改变整个风险分布？本综述更详细地讨论了这些问题，概述了每种方法的优缺点。
