College of Nursing and Health, Loyola University, New Orleans, LA, USA.
Division of Cardiology, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, PA, USA.
J Clin Lipidol. 2019 Mar-Apr;13(2):223-230. doi: 10.1016/j.jacl.2019.04.003.
This Roundtable discussion concerns atherogenic risk markers and treatment targets used by clinical lipidologists in daily practice. Our purpose is to understand the risk marker framework that supports and enables the new ACC/AHA/Multisociety Cholesterol Guidelines. Some biomarkers are highly associated with atherogenic risk but fail to qualify as treatment targets. Prominent examples are high-density lipoprotein cholesterol, for which targeted treatment has failed to reduce cardiovascular risk, and lipoprotein(a), which currently lacks a highly effective mode of treatment. As a consequence, guidelines have focused consistently on low-density lipoprotein cholesterol (LDL-C) and more recently on non-high-density lipoprotein cholesterol. We discuss a new calculation for LDL-C that shows greater accuracy than the commonly performed Friedewald calculation. LDL-C treatment goals have renewed prominence in the 2018 Guidelines. Thresholds for treatment initiation or intensification inherently establish goals of reducing atherogenic cholesterol levels below the thresholds. Treatment goals may be absolute, such as less than 70 mg/dL for LDL-C in very high-risk secondary prevention or relative, such as 50% or greater reduction of LDL-C. The timeframe of treatment is another consideration because milder treatment started earlier may sometimes be preferred over stronger treatment given late in the course of atherosclerotic progression. Advanced lipid testing and vascular imaging, particularly coronary artery calcium, also have their place in risk assessment to guide clinical lipid practice.
本次圆桌讨论涉及临床脂质学家在日常实践中使用的动脉粥样硬化风险标志物和治疗靶点。我们的目的是了解支持和实现新的 ACC/AHA/多学会胆固醇指南的风险标志物框架。一些生物标志物与动脉粥样硬化风险高度相关，但未能成为治疗靶点。高密度脂蛋白胆固醇就是一个突出的例子，针对该标志物的靶向治疗未能降低心血管风险，而脂蛋白(a)目前缺乏非常有效的治疗方法。因此，指南一直关注于低密度脂蛋白胆固醇（LDL-C），最近又关注于非高密度脂蛋白胆固醇。我们讨论了一种新的 LDL-C 计算方法，该方法比常用的 Friedewald 计算方法更准确。LDL-C 的治疗目标在 2018 年指南中重新受到重视。治疗起始或强化的阈值内在地确立了降低动脉粥样硬化胆固醇水平低于阈值的目标。治疗目标可以是绝对的，例如极高危二级预防中 LDL-C 低于 70mg/dL，也可以是相对的，例如 LDL-C 降低 50%或更多。治疗的时间框架也是一个需要考虑的因素，因为早期轻度治疗可能有时优于在动脉粥样硬化进展过程后期进行的强化治疗。高级脂质检测和血管成像，特别是冠状动脉钙，在风险评估中也有其位置，以指导临床脂质实践。
