acs降脂治疗高级班课件

急性冠脉综合症的降脂治疗

Lipid-loweringtreatmentofacutecoronarysyndromeContents概述1ACS与血脂关系2降脂治疗对ACS临床益处3ACS病理基础ACS斑块特征①大脂池（脂质核心占40%）②大量炎性细胞浸润③易损性（vulnerability）★血中血脂异常增高

★内皮细胞功能损伤★局部炎症

★血液动力学异常李娇娇.心血管病防治知识(下半月),2013,12:150-153ACS

血脂

关系ACS与血脂状态有报道ACS患者应激状态下，血脂浓度有较大波动。AMI发生24h后，TC、LDL-C、HDL-C、apoA1和apoB均有明显下降，TG却增加。4～5d后变化最为明显，2～3个月后可回到基线状态。此时LDL和HDL颗粒性质发生了变化。作者认为，对于ACS患者，无论基线血脂浓度如何，都需要积极地应用他汀类药物进行强化降脂治疗。赵水平.中华心血管病杂志,2013,41(7):

542-543结果结论：TC、TG、LDL-C、ApoB水平升高和HDL-C、ApoA1水平降低可能是ACS发病的危险因素，血脂6项指标联合检测有助于预测ACS的发生并监控病情的变化。丁玲新等.海南医学院学报,2011,11:1476-1478ACS与血脂状态另一篇报道：经冠脉造影诊断为CHD的367例患者，其中男性261例，女性106例，年龄29～89(59.5±11.0)岁。268例ACS患者，99例非ACS患者作为对照，对两组患者的Lp(a)、HDL-C、ApoAl、TC、TG、LDL-C以及ApoB水平进行观察。结果ACS与血脂状态另一项研究纳入333例ACS患者，男性232例（69.7%），女性101例（30.3%），年龄62±10.63岁。其中UA257例（77.2%），NSTEMI50例，STEMI26例（7.8%），在发病期对患者血浆血脂浓度进行检测。结果结论1.在ACS患者中，血脂异常较为常见2.大于50%是HDL-C＜1.0mmol/L孙斌.郑州大学,2010年,学位论文ACS降脂治疗临床益处Effects

of

atorvastatin

on

early

recurrentischemiceventsinacutecoronarysyndromes:theMIRACLstudy:arandomizedcontrolledtrial.★Arandomized,double-blindtrial★1997.5to1999.9★follow-up16weeks★122clinicalcentersinEurope,NorthAmerica,SouthAfrica,andAustralasia.★Atotalof3086adultsaged18yearsorolderwithunstableanginaornon-Q-waveacutemyocardialinfarction.★①Todeterminewhethertreatmentwith

atorvastatin

②80mg/datorvastatin,initiated24to96hoursafteranacutecoronarysyndromeRulstConclusion

Forpatientswithacutecoronarysyndrome,lipid-loweringtherapywithatorvastatin,80mg/d,reducesrecurrentischemiceventsinthefirst16weeks,mostlyrecurrentsymptomaticischemiarequiringrehospitalization.SchwartzGG，etal.JAMA.

2001

Apr4;285(13):1711-8.AtoZ(theAggrastattoZocor）Time:

December29,1999,andJanuary6,2003Design:

①patients(n=2265)withACSreceiving40mg/dofsimvastatinfor1monthfollowedby80mg/d

②patients(n=2232)withACSpatientsreceivingplacebofor4monthsfollowedby20mg/dofsimvastatinFollow-up:6～24months.Theprimaryendpoint:

CardiovasculardeathNonfatalmyocardialinfarctionReadmissionforACSStrokeAmongpatientswithACS,theearlyinitiationofanaggressivesimvastatinregimenresultedinafavorabletrendtowardreductionofmajorcardiovascularevents.Conclusions

ARMYDATrialPasceriV,etalCirculation2004;110:674-8AtorvastatinforReductionofMyocardialDamageDuringAngioplasty153patientsscheduledforelectivePCIirrespectiveofbaselinelipidlevelsRandomized,double-blindAtorvastatin40mg/dn=76Placebon=77EndPoints★Theprimaryendpoint：occurrenceofmyocardialinfarction（CK-MB>2times）★Secondaryendpoints：①othermarkersofmyocardialinjury（CK-MB,troponinIandmyoglobin）＞uppernormallimits②meanpeakvaluesofCK-MB,troponinIandmyoglobinafterintervention③occuringadversecardiacevents(death,myocardialinfarction,orneedforunplannedrevascularization)WithinamonthARMYDATrial

Primaryendpointofpost-procedureMI(CKMB>2xULN)↓inatorvastatingroupvsplacebo(Figure)Presenceofmarkers>1xULNalso↓inatorvastatinarm:CKMB12%vs35%,p=0.001;troponinI20%vs48%p=0.0004;myoglobin22%vs51%,p=0.0005Circulation2004;110:674-8Post-procedureMI(>2xULN)p=0.025ARMYDATrialCirculation2004;110:674-8

PeakvaluesofCK-MB,troponinI,andmyoglobininstatinvsplacebogroup.Dataaremean±SEM.pretreatmentwithatorvastatinsignificantlyreducedriskofperiproceduralmyocardialinfarction(OR0.19,95%CI0.05to0.57).Useofβ-blockers,glycoproteinIIb/IIIainhibitors,orACEinhibitorswasnotassociatedwithriskreduction.ARMYDATrial

AmongpatientsundergoingelectivePCI,pre-treatmentwithatorvastatinwasassociatedwithareductioninmarkersofmyocardialinjurypost-procedureMechanismmayberelatedtoanti-inflammatoryeffectofstatins国内研究68例血脂正常ACS患者被随机分为常规治疗组（34例，仅常规治疗），和辛伐他汀组（34例，常规治疗基础上加用辛伐他汀20mg/d），疗程6个月。于治疗前、后8周检测血浆BNP、hsCRP水平。所有患者每3个月随访一次，平均随访观察6个月，以住院或观察期间的心血管事件为终点。结论血脂正常的ACS患者，早期应用辛伐他汀干预可以显著降低血浆BNP、hs-CRP水平，减轻炎症反应，稳定动脉粥样硬化斑块减少心血管管事件发生。翁根龙.心血管康复医学杂志，2012，21(1):70-72国内研究52例ACS患者随机分成3组，A组（常规治疗）；B组：辛伐他汀20mg/d，C组：辛伐他汀40mg/d，随访观察3组患者首次入院后1个月和1年的终点事件发生率(死亡、再发心绞痛或心肌梗死、再入院率)以及血脂水平、肝肾功能和不良反应结果。TC≥4.68mmol/L