Vikulova Diana N, Pinheiro-Muller Danielle, Rojas-Fernandez Carlos, Leblond Francois, Pimstone Simon N, Brunham Liam R
Centre for Heart Lung Innovation, University of British Columbia, Vancouver, Canada.
Department of Medicine, University of British Columbia, Vancouver, Canada.
JACC Adv. 2023 Nov 14;2(10):100696. doi: 10.1016/j.jacadv.2023.100696. eCollection 2023 Dec.
Lipid-lowering therapy (LLT) is a central aspect of the treatment of patients with coronary artery disease (CAD), and the benefits of LLT accrue over time. However, there are limited real-world data on longitudinal lipid control in patients with premature CAD.
The purpose of this study was to assess longitudinal attainment of guideline-recommended lipid goals and outcomes in a contemporary cohort of patients with premature CAD.
We enrolled males younger than 50 years and females younger than 55 years with coronary stenosis of >50% and examined achievement of lipid goals, LLT characteristics, and cardiovascular outcomes (major adverse cardiovascular event [MACE]).
Of 476 patients who presented with acute coronary syndrome (ST-elevation myocardial infarction, non-ST-segment elevation myocardial infarction, unstable angina) (68%), stable angina (28%), or other symptoms, 73.2% achieved low-density lipoprotein cholesterol (LDL-C) <1.8 mmol/L on at least 1 occasion, but only 27.3% consistently stayed in the target range for 3 years after diagnosis. Although 73.9% of patients received high-intensity LLT at the time of diagnosis, only 43.5% had good adherence over the following 3 years. In multivariable analysis, 1 mmol/L increase in time-weighted average exposure to LDL-C, but not the lowest achieved LDL-C, was associated with a higher risk of MACE, hazard ratio 2.02 (95% CI: 1.48-2.76), when adjusted for sex, age, hypertension, diabetes, and smoking.
We found low rates of longitudinal lipid target achievement in patients with premature CAD. Cumulative LDL-C exposure, but not lowest achieved LDL-C, was associated with risk of MACE. This highlights the critical importance of longitudinal control of lipids levels and identifies opportunities to improve LLT and maximize the time-dependent benefits of lipid-lowering.
降脂治疗（LLT）是冠状动脉疾病（CAD）患者治疗的核心环节，且降脂治疗的益处会随着时间积累。然而，关于早发性CAD患者长期血脂控制的真实世界数据有限。
本研究旨在评估当代早发性CAD患者队列中，指南推荐的血脂目标的纵向达成情况及预后。
我们纳入了年龄小于50岁的男性和年龄小于55岁、冠状动脉狭窄超过50%的女性，检查血脂目标的达成情况、LLT特征和心血管预后（主要不良心血管事件 [MACE]）。
在476例出现急性冠状动脉综合征（ST段抬高型心肌梗死、非ST段抬高型心肌梗死、不稳定型心绞痛）（68%）、稳定型心绞痛（28%）或其他症状的患者中，73.2%至少有一次低密度脂蛋白胆固醇（LDL-C）<1.8 mmol/L，但诊断后3年仅有27.3%持续保持在目标范围内。尽管73.9%的患者在诊断时接受了高强度LLT，但在接下来的3年中只有43.5%有良好的依从性。在多变量分析中，调整性别、年龄、高血压、糖尿病和吸烟因素后，LDL-C的时间加权平均暴露量每增加1 mmol/L，而非最低达到的LDL-C水平，与MACE风险较高相关，风险比为2.02（95% CI：1.48 - 2.76）。
我们发现早发性CAD患者长期血脂目标达成率较低。LDL-C的累积暴露量而非最低达到的LDL-C水平与MACE风险相关。这凸显了长期控制血脂水平的关键重要性，并确定了改善LLT和最大化降脂时间依赖性益处的机会。
