Langer Anatoly, Tan Mary, Goodman Shaun G, Grégoire Jean, Lin Peter J, Mancini G B John, Stone James A, Wills Cheryll, Spindler Caroline, Leiter Lawrence A
Canadian Heart Research Centre, North York, Ontario, Canada.
St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
CJC Open. 2019 Dec 28;2(2):49-54. doi: 10.1016/j.cjco.2019.12.002. eCollection 2020 Mar.
Despite the widespread use of statins, approximately 40% to 50% of Canadian patients with known cardiovascular disease do not achieve the low-density lipoprotein cholesterol (LDL-C) goal. uidelines riented pproach to ipid lowering (GOAL) is an investigator-initiated study aiming to ascertain the use of second- and third-line therapy and its impact on LDL-C goal achievement in a real-world setting.
GOAL enrolled patients with clinical vascular disease or familial hypercholesterolemia and LDL-C > 2.0 mmol/L despite maximally tolerated statin therapy. During follow-up, physicians managed patients as clinically indicated but with online reminders of guideline recommendations.
Of 2009 patients enrolled (median age 63 years, 42% were female), baseline total cholesterol was 5.5 ± 1.4 mmol/L, LDL-C was 3.3 ± 1.3 mmol/L, non-high-density lipoprotein cholesterol was 4.1 ± 1.4 mmol/L, high-density lipoprotein cholesterol was 1.3 ± 0.4 mmol/L, and triglycerides were 2.0 ± 1.5 mmol/L. Lipid-lowering therapy used at baseline was statin therapy in 76% (with 24% statin intolerant) and ezetimibe in 25%. During follow-up, the proportion of patients achieving an LDL-C level of < 2.0 mmol/L increased significantly to 50.8% as a result of additional lipid-lowering therapy. Patients achieving the recommended LDL-C level were more likely to not be statin intolerant (83.8% vs 70.7%, 0.0001) and to be taking a high-efficacy type and dose of statin (52.4% vs 35.9%, 0.0001). The 3 top reasons for not using the recommended therapy with ezetimibe were patient refusal in 33%, not needed in 22%, and intolerance in 20%, whereas for PCSK9i the reasons were cost in 26%, not needed in 27%, or patient refusal in 25%.
The results indicate the feasibility of optimizing management, resulting in achievement of the guideline-recommended LDL-C level. This has the potential to translate into reductions in cardiovascular morbidity and mortality of Canadian patients.
尽管他汀类药物被广泛使用，但在已知患有心血管疾病的加拿大患者中，约40%至50%未达到低密度脂蛋白胆固醇（LDL-C）目标。以指南为导向的降脂方法（GOAL）是一项由研究者发起的研究，旨在确定二线和三线治疗的使用情况及其在现实环境中对实现LDL-C目标的影响。
GOAL纳入了患有临床血管疾病或家族性高胆固醇血症且尽管接受了最大耐受剂量的他汀类药物治疗但LDL-C>2.0 mmol/L的患者。在随访期间，医生根据临床指征对患者进行管理，但会收到关于指南建议的在线提醒。
在纳入的2009例患者中（中位年龄63岁，42%为女性），基线总胆固醇为5.5±1.4 mmol/L，LDL-C为3.3±1.3 mmol/L，非高密度脂蛋白胆固醇为4.1±1.4 mmol/L，高密度脂蛋白胆固醇为1.3±0.4 mmol/L，甘油三酯为2.0±1.5 mmol/L。基线时使用的降脂治疗中，76%为他汀类药物治疗（其中24%对他汀类药物不耐受），25%为依折麦布。在随访期间，由于额外的降脂治疗，LDL-C水平<2.0 mmol/L的患者比例显著增加至50.8%。达到推荐LDL-C水平的患者更有可能对他汀类药物不耐受（83.8%对70.7%，P<0.0001），并且正在服用高效类型和剂量的他汀类药物（52.4%对35.9%，P<0.0001）。不使用推荐的依折麦布治疗的三大原因是患者拒绝（33%）、不需要（22%）和不耐受（20%），而对于PCSK9i，原因是费用（26%）、不需要（27%）或患者拒绝（25%）。
结果表明优化管理是可行的，从而实现了指南推荐的LDL-C水平。这有可能降低加拿大患者的心血管发病率和死亡率。
