Gotto A M
Department of Medicine, Baylor College of Medicine, Houston, Texas 77030.
Am J Med. 1994 Jun 6;96(6A):9S-18S. doi: 10.1016/0002-9343(94)90226-7.
There appears to be little doubt that lowering serum cholesterol for reduction of risk for coronary artery disease (CAD) events in patients with established CAD is cost-effective and can decrease the rate of CAD events, stabilize atherosclerotic plaque progression, and reduce CAD mortality and all-cause mortality. Meta-analysis of clinical trials conducted in patients with CAD has shown a 26% reduction in CAD events and a 9% reduction in total mortality. It was generalized from the results of nine major, recent angiographically monitored clinical trials that an improvement in obstruction was seen in 8% of control patients and 25% of treated patients. In the recently released report of the second Adult Treatment Panel (ATP II) of the U.S. National Cholesterol Education Program, atherosclerotic disease status joins low-density lipoprotein cholesterol (LDL-C) level as central to the diagnosis and treatment algorithm. The ATP II evaluation process is divided into two categories according to whether atherosclerotic disease is present, and a lower LDL-C target level--100 mg/dL (2.6 mmol/L)--is set for secondary prevention. Initial therapy when LDL-C is > or = 100 mg/dL in a patient with atherosclerotic disease is the Step Two Diet, weight control, exercise, and control of other risk factors. Drug therapy may be considered after a relatively short trial of hygienic therapy if LDL-C remains > or = 130 mg/dL (3.4 mmol/L). Other, selected aspects of heart disease for general consideration in assessing CAD risk are family history and the presence of left ventricular hypertrophy (LVH). Family history of premature CAD is included in the ATP II algorithm, with different age considerations by gender added. Although LVH is not part of ATP II risk assessment, its presence as defined by echocardiography increases CAD risk six- to eightfold in both men and women.
对于已确诊冠心病（CAD）的患者，降低血清胆固醇以降低CAD事件风险似乎毫无疑问是具有成本效益的，并且可以降低CAD事件发生率、稳定动脉粥样硬化斑块进展、降低CAD死亡率和全因死亡率。对CAD患者进行的临床试验的荟萃分析表明，CAD事件减少了26%，总死亡率降低了9%。从最近九项主要的、经血管造影监测的临床试验结果推断，在对照组患者中有8%出现阻塞改善，而治疗组患者中有25%出现阻塞改善。在美国国家胆固醇教育计划的第二次成人治疗小组（ATP II）最近发布的报告中，动脉粥样硬化疾病状态与低密度脂蛋白胆固醇（LDL-C）水平一起成为诊断和治疗算法的核心。ATP II评估过程根据是否存在动脉粥样硬化疾病分为两类，并且为二级预防设定了更低的LDL-C目标水平——100毫克/分升（2.6毫摩尔/升）。对于患有动脉粥样硬化疾病且LDL-C≥100毫克/分升的患者，初始治疗是第二步饮食、体重控制、运动以及控制其他危险因素。如果在进行相对较短时间的卫生治疗试验后LDL-C仍≥130毫克/分升（3.4毫摩尔/升），则可考虑药物治疗。在评估CAD风险时一般需要综合考虑的其他选定的心脏病方面包括家族史和左心室肥厚（LVH）的存在。ATP II算法纳入了早发CAD家族史，并根据性别增加了不同的年龄考量。尽管LVH不是ATP II风险评估的一部分，但超声心动图定义的LVH的存在会使男性和女性的CAD风险增加6至8倍。
