Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
J Am Coll Cardiol. 2020 Aug 11;76(6):653-664. doi: 10.1016/j.jacc.2020.06.030.
The 2018 cholesterol guidelines of the American Heart Association and the American College of Cardiology (AHA/ACC) changed 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitor (statin) eligibility criteria for primary prevention to include multiple risk enhancers and novel intensive lipid-lowering therapies for secondary prevention.
This study sought to determine how guideline changes affected identification for preventive therapy in young adults with premature myocardial infarction (MI).
The study identified adults presenting with first MI at Duke University Medical Center in Durham, North Carolina. Statin therapy eligibility was determined using the 2013 ACC/AHA and 2018 AHA/ACC guidelines criteria. The study also determined potential eligibility for intensive lipid-lowering therapies (very high risk) under the 2018 AHA/ACC guidelines, by assessing the composite of all-cause death, recurrent MI, or stroke rates in adults considered "very high risk" versus not.
Among 6,639 patients with MI, 41% were <55 years of age ("younger"), 35% were 55 to 65 years of age ("middle-aged"), and 24% were 66 to 75 years of age ("older"). Younger adults were more frequently smokers (52% vs. 38% vs. 22%, respectively) and obese (42% vs. 34% vs. 31%, respectively), with metabolic syndrome (21% vs. 19% vs. 17%, respectively) and higher low-density lipoprotein cholesterol (117 vs. 107 vs. 103 mg/dl, respectively) (p trend <0.01 for all). Pre-MI, fewer younger adults met guideline indications for 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitor (statin) therapy than middle-aged and older adults. The 2018 guideline identified fewer younger adults eligible for statin therapy at the time of their MI than the 2013 guideline (46.4% vs. 56.7%; p < 0.01). Younger patients less frequently met very high-risk criteria for intensive secondary prevention lipid-lowering therapy (28.3% vs. 40.0% vs. 81.4%, respectively; p < 0.01). Over a median 8 years of follow-up, very high-risk criteria were associated with increased risk of major adverse cardiovascular events in individuals <55 years of age (hazard ratio: 2.09; 95% confidence interval: 1.82 to 2.41; p < 0.001), as was the case in older age groups (p interaction = 0.54).
Most younger patients with premature MI are not identified as statin candidates before their event on the basis of the 2018 guidelines, and most patients with premature MI are not recommended for intensive post-MI lipid management.
美国心脏协会和美国心脏病学会（AHA/ACC）的 2018 年胆固醇指南改变了一级预防中 3-羟基-3-甲基戊二酰基辅酶 A 还原酶抑制剂（他汀类药物）的入选标准，纳入了多种风险增强因子和新型强化降脂疗法用于二级预防。
本研究旨在确定指南的改变如何影响年轻的早发性心肌梗死（MI）患者的预防性治疗。
该研究在北卡罗来纳州达勒姆市的杜克大学医学中心确定了首次出现 MI 的成年人。使用 2013 年 ACC/AHA 和 2018 年 AHA/ACC 指南标准来确定他汀类药物的使用适应证。通过评估被认为“极高危”的成年人与非极高危成年人之间的全因死亡率、复发性 MI 或中风率的复合指标，还确定了 2018 年 AHA/ACC 指南下强化降脂治疗（极高危）的潜在适应证。
在 6639 例 MI 患者中，41%年龄<55 岁（“年轻”），35%年龄为 55 岁至 65 岁（“中年”），24%年龄为 66 岁至 75 岁（“老年”）。年轻患者更频繁地吸烟（52%比 38%比 22%）和肥胖（42%比 34%比 31%），代谢综合征（21%比 19%比 17%）和低密度脂蛋白胆固醇水平更高（117 比 107 比 103 mg/dl）（p 趋势<0.01）。在发生 MI 之前，与中年和老年患者相比，年轻患者符合他汀类药物治疗的指南指征的比例更低。与 2013 年指南相比，2018 年指南确定的年轻患者适合他汀类药物治疗的比例更低（46.4%比 56.7%；p<0.01）。年轻患者符合强化二级预防降脂治疗极高危标准的比例较低（28.3%比 40.0%比 81.4%；p<0.01）。在中位 8 年的随访期间，极高危标准与<55 岁个体的主要不良心血管事件风险增加相关（风险比：2.09；95%置信区间：1.82 至 2.41；p<0.001），在老年组中也是如此（p 交互=0.54）。
根据 2018 年指南，大多数年轻的早发性 MI 患者在发生事件之前并未被确定为他汀类药物候选者，大多数早发性 MI 患者未被建议进行强化 MI 后降脂治疗。
