Frohlich J J
St Paul's Hospital, Lipid Clinic, Vancouver, British Columbia.
Can J Cardiol. 1995 May;11 Suppl C:18C-23C.
Two new important independent risk factors for coronary artery disease (CAD) have been identified: lipoprotein (a) [Lp(a)] and homocyst(e)ine. Both are associated with increased frequency of cardiovascular events, both coronary and peripheral. Measurement of these two factors should be considered in patients with symptomatic CAD, stroke, a strong family history (but low other conventional risk factors); in first degree relatives of those with very high Lp(a) or homocyst(e)ine levels; and in other individuals in whom the need for an aggressive treatment of metabolic risk factors is indicated. While treatment of high serum Lp(a) with drugs is difficult it appears from the epidemiological or clinical evidence that the additional risk due to Lp(a) can be drastically lowered by decreasing the patient's low density lipoprotein (LDL) cholesterol levels to below 3 mmol/L. The treatment of increased homocyst(e)ine can be easily accomplished by vitamin B6 or folic acid administration. Various analyses describing the value of positive tests for diagnosis of atherosclerosis indicate that overall risk evaluated by computer models from Framingham data, use of total: high density lipoprotein (HDL) cholesterol ratio and/or the National Cholesterol Education Program (NCEP) II guidelines are the best predictors of future cardiovascular events. The strategic aim for treatment regimens should be threefold: lower serum LDL cholesterol levels; decrease serum triglycerides (and triglyceride-rich lipoproteins); and increase HDL cholesterol. Niacin and statin drugs are the most cost effective means to achieve the former and niacin and fibrates to achieve the latter goal. Where target LDL cholesterol levels can be achieved with less expensive statin preparations their use may be economically advantageous.
已确定冠心病（CAD）的两个新的重要独立危险因素：脂蛋白（a）[Lp（a）]和同型半胱氨酸。两者都与心血管事件（包括冠状动脉和外周血管事件）发生频率增加相关。对于有症状的CAD患者、中风患者、有强烈家族病史（但其他传统危险因素较低）的患者；Lp（a）或同型半胱氨酸水平非常高的患者的一级亲属；以及其他表明需要积极治疗代谢危险因素的个体，应考虑检测这两个因素。虽然用药物治疗高血清Lp（a）很困难，但从流行病学或临床证据来看，通过将患者的低密度脂蛋白（LDL）胆固醇水平降至3 mmol/L以下，可大幅降低因Lp（a）导致的额外风险。补充维生素B6或叶酸可轻松治疗升高的同型半胱氨酸。各种描述动脉粥样硬化诊断阳性试验价值的分析表明，根据弗雷明汉数据通过计算机模型评估的总体风险、使用总胆固醇：高密度脂蛋白（HDL）胆固醇比率和/或美国国家胆固醇教育计划（NCEP）II指南是未来心血管事件的最佳预测指标。治疗方案的战略目标应包括三个方面：降低血清LDL胆固醇水平；降低血清甘油三酯（以及富含甘油三酯的脂蛋白）；提高HDL胆固醇。烟酸和他汀类药物是实现前者最具成本效益的手段，烟酸和贝特类药物是实现后者目标的手段。如果使用较便宜的他汀类制剂就能达到目标LDL胆固醇水平，那么使用它们在经济上可能更具优势。
