Imperial Centre for Cardiovascular Disease Prevention (ICCP), Department of Primary Care and Public Health, School of Public Health, Imperial College London, St.Dunstan's Road, London, W6 8RP, UK; Department of Cardiovascular Medicine, Saga University, 5-1-1 Nabeshima, Saga, Japan.
Pfizer Inc., 235 E 42nd St, New York, USA.
Atherosclerosis. 2021 Apr;322:8-14. doi: 10.1016/j.atherosclerosis.2021.02.011. Epub 2021 Feb 20.
Despite trial evidence, high intensity statins are underutilized in routine clinical practice. This study sought to assess the individual and joint contributions of the TRS2P score as a measure of residual risk and LDL-C levels to benefits from further LDL-C lowering in the TNT trial.
A total of 9980 patients were divided into 4 groups based on TRS2P and LDL-C at baseline: <median TRS2P and <median LDL-C (group 1), <median TRS2P and ≥median LDL-C (group 2), ≥median TRS2P and <median LDL-C (group 3), ≥median TRS2P and ≥median LDL-C (group 4). The effect of atorvastatin 80 mg vs. 10 mg on the risk of any cardiovascular event was assessed among the groups.
Percentage reductions in LDL-C with atorvastatin 80 mg were consistent across groups, whereas absolute reductions were approximately 11 mg/dL greater when LDL-C was ≥median. Despite atorvastatin 10 mg, either TRS2P ≥ median or LDL-C ≥ median were associated with more events and highest when both were ≥median (groups 1-4; 21.5%, 28.1%, 36.3%, and 40.5%, respectively; p-trend <0.0001. Although relative benefits were similar, absolute risk reduction from atorvastatin 80 mg was lowest when both scores were <median (1.3%, group 1) and highest when both were >median (7.2%, group 4), NNT 78 vs. 14 (p-interaction <0.0001).
Measures of residual risk as well LDL-C identify patients who remain at high risk despite statins with the combination identifying those who derive the greatest benefits from even modest additional LDL-C lowering. Attention to residual risk as well as LDL-C may further help to optimize guideline implementation.
尽管有试验证据，但高强度他汀类药物在常规临床实践中仍未得到充分应用。本研究旨在评估 TRS2P 评分作为残余风险和 LDL-C 水平的衡量标准，以评估 TNT 试验中进一步降低 LDL-C 水平的获益。
共有 9980 名患者根据基线时的 TRS2P 和 LDL-C 分为 4 组：<中位数 TRS2P 和 <中位数 LDL-C（组 1）、<中位数 TRS2P 和 ≥中位数 LDL-C（组 2）、≥中位数 TRS2P 和 <中位数 LDL-C（组 3）、≥中位数 TRS2P 和 ≥中位数 LDL-C（组 4）。评估阿托伐他汀 80mg 与 10mg 对各组发生任何心血管事件风险的影响。
阿托伐他汀 80mg 降低 LDL-C 的百分比在各组之间一致，而当 LDL-C≥中位数时，绝对降低约 11mg/dL。尽管使用了阿托伐他汀 10mg，但无论 TRS2P 是否≥中位数，只要 LDL-C≥中位数，事件发生的风险就会增加，当两者都≥中位数时风险最高（组 1-4：分别为 21.5%、28.1%、36.3%和 40.5%；p 趋势<0.0001）。虽然相对获益相似，但当两项评分均<中位数时，阿托伐他汀 80mg 的绝对风险降低最低（组 1，1.3%），当两项评分均>中位数时最高（组 4，7.2%），NNT 为 78 与 14（p 交互作用<0.0001）。
残余风险和 LDL-C 可识别出即使使用他汀类药物仍处于高风险的患者，两者联合可识别出从适度增加 LDL-C 降低中获益最大的患者。关注残余风险和 LDL-C 可能有助于进一步优化指南的实施。
