ATPIII：识别和治疗高危患者的新方法课件.ppt

1、0.01.02.03.04.05.06.0Hospitalization for MI(per 1,000)*Age-adjusted19871989199019921988199319941991Rosamond WD et al.N Engl J Med 1998;339:861-867.1998 Massachusetts Medical Society.All rights reserved.MenWomen1.The risk of vascular disease is similar in CHD equivalents and in patients with CHD.2.Li

2、pid interventions to reduce CHD can be equally effective in CHD equivalent and CHD patients.3.In diabetic patients,glycemia alone will not completely eliminate the excess CHD risk.n20%10-year risk of CHD(Framingham projections)nDiabetesnOther forms of clinical atherosclerotic disease:Peripheral arte

3、rial disease Abdominal aortic aneurysm Carotid artery diseaseExpert Panel on Detection,Evaluation,and Treatment of High Blood Cholesterol in Adults.JAMA 2001;285:2486-2497.nAtherosclerotic disease in one region of the arterial tree is associated with and predicts disease in other arterial regions Pa

4、thobiology and predisposing risk factors are similar for atherosclerosis in coronary,peripheral,and carotid arteriesnThus,clinical atherosclerotic disease in noncoronary arteries is a powerful predictor of CHDnStudies of patients with atherosclerotic PAD support the concept that PAD,regardless of di

5、agnosis by ABI,lower limb blood flow studies,or clinical symptoms,is a CHD risk equivalentn Ankle/brachial blood pressure index(ABI)in randomly selected population,5-year follow-upn 1592 men and women,614 with CHD,aged 5574n 137 fatal and nonfatal CHD events during follow-up1.11.11.011.00.910.90.710

6、.7ABICHD Event Outcomes per Year(%)Leng GC et al.BMJ 1996;313:1440-1444.1.4%3.8%01234n Study population:300 men and 43 women(aged 4589)operated on for AAA,separated into 4 groups based on preoperative CHD history and ECGn Follow-up:611 yearsn Results:annual CHD mortality 1.9%in persons with no sympt

7、oms,no prior history of CHD,and normal ECG(31%)2.0%in persons with no symptoms,but previous MI by ECG(33%)3.9%in persons with angina/prior MI(30%)n Because the rate of CHD events is at least twice that of CHD mortality,patients with no previous history of CHD events would fall into the CHD risk equi

8、valent categoryHertzer NR.Ann Surg 1980;192:667-673.n North American Symptomatic Carotid Endarterectomy Trial(NASCET)Symptomatic patients undergoing carotid endarterectomy had an average 10-year CHD mortality of 19%n European Carotid Surgery Trial(ECST)Symptomatic patients had very high death rates

9、from nonstroke vascular disease regardless of the percent of carotid artery stenosis at the onset 72%of deaths were due to nonstroke vascular disease and thus 10-year CHD death is estimated at 30%Ferguson GG et al.Stroke 1999;30:1751-1758.|Barnett HJ et al.N Engl J Med 1998;339:1415-1425.|ECST Colla

10、borative Group.Lancet 1998;351:1379-1387.n Mayo Asymptomatic Carotid Atherosclerosis Study Subjects 158 patients,40%with history of CAD,15%diabetic Disease severity Asymptomatic stenosis 50%Trial stopped because of high MI and TIA event rate in surgical arm secondary to cessation of medical therapy(

11、aspirin)CHD events After 2.5-year follow-up:12 CHD events Estimated 10-year CHD event rate=30%Executive Committee for the Asymptomatic Carotid Atherosclerosis Study.JAMA 1995;273:1421-1428.Baseline featureSimvastatin(n=10,269)Placebo(n=10,267)Previous MI10071255Other CHD(not MI)9141234No prior CHDCV

12、D182215PVD332427Diabetes279369All patients2042 (19.9%)2606(25.4%)Collins R.Presented at AHA,Anaheim,California,13 November 2001.Risk ratio and 95%CIStatin betterStatin worse 24 2.6%(2P 200 mg/dL SBP 120 mm Hg Current smoker020406080100120%MortalityMiettinen H et al.Diabetes Care 1998;21:69-75.010203

13、0405001020304050Haffner SM et al.N Engl J Med 1998;339:229-234.Fatal or Nonfatal MI(%)Prior MI18.83.545.020.2P0.001P0.001Prior MINo prior MINo prior MINondiabetic subjectsDiabetic subjects(n=1373)(n=1059)0.000.050.100.150.200.25Event RateMonths69153182112Malmberg K et al.Circulation 2000;102:1014-10

14、19.2000 Lippincott Williams&Wilkins.24AFCAPS/TexCAPSLovastatin155150(3.9)25%HPSSimvastatin3985127(3.3)30%CAREPravastatin586136(3.6)28%4SSimvastatin202186(4.8)36%LIPID*Pravastatin782150(3.9)25%HPSSimvastatin1978127(3.3)30%*LDL-C values for overall group Downs JR et al.JAMA 1998;279:1615-1622.|HPS Inv

15、estigators.Presented at AHA,2001.|Goldberg RB et al.Circulation 1998;98:2513-2519.|Pyorala K et al.Diabetes Care 1997;20:614-620.|Haffner SM et al.Arch Intern Med 1999;159:2661-2667.|LIPID Study Group.N Engl J Med 1998;339:1349-1357.AFCAPS/TexCAPSLovastatin15537%43%(NS)HPSSimvastatin398524%26%(p.000

16、01)CARE Pravastatin58623%25%(p=.05)4SSimvastatin20232%55%(p=.002)LIPIDPravastatin78225%19%4S ReanalysisSimvastatin48332%42%(p=.001)HPSSimvastatin197824%unreportedDowns JR et al.JAMA 1998;279:1615-1622.|HPS Investigators.Presented at AHA,2001.|Goldberg RB et al.Circulation 1998;98:2513-2519.|Pyorala

17、K et al.Diabetes Care 1997;20:614-620.|LIPID Study Group.N Engl J Med 1998;339:1349-1357.|Haffner SM et al.Arch Intern Med 1999;159:2661-2667.Helsinki Heart StudyGemfibrozil(1200 mg/d)135203(5.2)6%68%NSVA-HIT Gemfibrozil(1200 mg/d)627112*(2.9*)24%P=.05 DAISFenofibrate(200 mg/d)4181306%23%NS*Median v

18、alueKoskinen P et al.Diabetes Care 1992;15:820-825.|Rubins HB et al.N Engl J Med 1999;341:410-418.|DAIS Investigators.Lancet 2001;357:905-910.Adler AI et al.BMJ 2000;321:412-419.|Stratton IM et al.BMJ 2000;321:405-412.Reprinted with permission from the BMJ Publishing Group.Adjusted incidence per 100

19、0 person-years(%)Updated mean HbA1c concentration(%)Updated mean systolic BP(mm Hg)02040608001020304050Adjusted incidence per 1000 person-years(%)567891011110 120 130 140 150 160 170MIMicrovascular end pointsMicrovascular end pointsMInImplies that enhanced benefit will be achieved from aggressive LD

20、L-lowering therapynPost-hoc analysis of all statin trials showed a trend for benefit of LDL lowering in persons with diabetesnPrimary target of therapy:LDL-CnDiabetes:CHD risk equivalentnTherefore,goal for persons with diabetes:100 mg/dL nTherapeutic options:LDL-C 100129 mg/dL:increase intensity of

21、TLC;add drug to modify atherogenic dyslipidemia(fibrate or nicotinic acid);intensify statin therapy LDL-C 130 mg/dL:simultaneously initiate TLC and LDL-Clowering drugsnAfter LDL-C goal is met,if TG 200 mg/dL:nonHDL-C(102 cm(40 in)88 cm(35 in)TG150 mg/dLHDL-C Men Women40 mg/dL102 cm 88 cmTGNot includ

22、ed*150 mg/dLHDL-C Men Women40 mg/dL40 mg/dL40 mg/dL50 mg/dLBlood pressure140/90 mm Hg130/85 mm HgFasting glucoseNot included 110 mg/dL*TG 200 mg/dL part of criteria to determine whether non-HDL-C should be targeted.Diabetes is a CHD risk equivalent.Diabetes plus IFG.Expert Panel on Detection,Evaluat

23、ion,and Treatment of High Blood Cholesterol in Adults.JAMA 2001;285:2486-2497.Risk FactorRisk Factor CountingMetabolic SyndromeCigarette smokingIncludedNot includedFamily history of CHDIncludedNot includedAge Men(45)Women(55)IncludedIncludedNot includedNot includedNegative risk factor HDL 60 mg/dLIn

24、cludedNot includedExpert Panel on Detection,Evaluation,and Treatment of High Blood Cholesterol in Adults.JAMA 2001;285:2486-2497.Baseline InsulinDisorderLow(%)High(%)RelativeRiskP ValueHypertension5.511.42.040.21Hypertriglyceridemia2.68.93.46.001Low HDL-C16.226.31.630.012High LDL-C16.420.11.230.223T

25、ype 2 diabetes2.212.35.62.001Haffner SM et al.Diabetes 1992;41:715-722.0.700.750.800.850.900.951.00Years5102001525Pyorala M et al.Circulation 1998;98:398-404.1998 Lippincott Williams&Wilkins.Log rank:Overall P=.001Q5 vs.Q1 P 20%10-year CHD risk)Type 2 diabetes mellitus Peripheral arterial disease Ab

26、dominal aortic aneurysm Carotid artery diseaseExpert Panel on Detection,Evaluation,and Treatment of High Blood Cholesterol in Adults.JAMA 2001;285:2486-2497.Triglyceride CategoryATP II LevelsATP III LevelsNormal200 mg/dL1000 mg/dL 500 mg/dLExpert Panel on Detection,Evaluation,and Treatment of High B

27、lood Cholesterol in Adults.JAMA 1993;269:3015-3023.|Expert Panel on Detection,Evaluation,and Treatment of High Blood Cholesterol in Adults.JAMA 2001;285:2486-2497.nATP III gives additional emphasis to moderate elevations of triglycerides(150200 mg/dL)for the following reasons:New meta-analysis sugge

28、sts that raised triglyceride levels may be an independent risk factor for CHD.12 Elevated triglycerides are associated with components of the metabolic syndrome such as glucose intolerance,low HDL,inflammation,and prothrombotic state.3 Subjects with modestly elevated triglyceride levels have atherog

29、enic remnant lipoproteins.3 nIncreased triglycerides are not a specific target for intervention in ATP III but enter into the determination of whether to target non-HDL-C.1 Austin MA.Can J Cardiol 1998;14:14B-17B.2 Assmann G et al.Eur Heart J 1998;19:M8-M14.3 Grundy SM.Am J Cardiol 1998;81:18B-25B.H

30、DL-C CategoryATP II LevelsATP III LevelsLow HDL-C35 mg/dL40 mg/dLHigh HDL-C 60 mg/dL 60 mg/dLExpert Panel on Detection,Evaluation,and Treatment of High Blood Cholesterol in Adults.JAMA 1993;269:3015-3023.|Expert Panel on Detection,Evaluation,and Treatment of High Blood Cholesterol in Adults.JAMA 200

31、1;285:2486-2497.nThe inverse association between HDL-C concentrations and CHD risk is continuous;no threshold relationship has been identified.Clearly,low HDL-C levels predict CHD at levels above 35 mg/dL.1nWomen typically have higher HDL-C levels than men,and a cutpoint of 40 mg/dL will identify mo

32、re men than women with low HDL-C,i.e.,approximately one-third of men and one-fifth of women in the general population.1 Wilson PW et al.Circulation 1998;97:1837-1847.nNon-HDL-C=TC HDL-CnCan be accurately measured in nonfasting statenApo B concentration represents total number of lipoprotein particle

33、s(LDL+IDL+VLDL)nThis may be called“non-HDL”cholesterol or“atherogenic cholesterol”Grundy SM.Circulation 1997;95:1-4.Cui Y et al.Arch Intern Med 2001;161:1413-1419.LRC=Lipid Research Clinics;RR=Relative risk;CI=confidence interval.00.250.50 0.75 1.001.251.501.75 2.002.25 2.502.753.00RR with 95%CINon-

34、HDL-C(mg/dL)Rate/10,00016038.0160 to 19043.0190 to 22053.922080.6LDL-C(mg/dL)13040.2130 to 16048.2160 to 19054.919071.3Cui Y et al.Arch Intern Med 2001;161:1413-1419.LRC=Lipid Research Clinics;RR=Relative risk;CI=confidence interval.0 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00RR with 95%CINon-HDL-C(mg/

35、dL)Rate/10,00016017.6160 to 19026.5190 to 22029.222051.3LDL-C(mg/dL)13025.4130 to 16022.8160 to 19027.719040.1Ballantyne CM et al.Am J Cardiol 2001;88:265269.2001,Reprinted with permission from Excerpta Medica Inc.Non-HDL-C and apo BLDL-C and apo BAll patients0.9380.849Baseline TG stratumTG 250 mg/d

36、L0.9460.9440.9000.9220.8850.805ATP II risk category2 RF without CHD2 RF without CHDCHD0.9080.9360.9290.8550.8350.810All p values 20%)1302+risk factors(10-yr risk 20%)16001 risk factor190Expert Panel on Detection,Evaluation,and Treatment of High Blood Cholesterol in Adults.JAMA 2001;285:2486-2497.nIn

37、creased number of patients with CHD equivalent with LDL-C goal 100 mg/dLnNew criteria for HDL-C,TG,and the metabolic syndromenNew targets for non-HDL-C in patients with TG 200 mg/dL演讲完毕，谢谢观看！Thank you for reading!In order to facilitate learning and use,the content of this document can be modified,adjusted and printed at will after downloading.Welcome to download!汇报人：XXX 汇报日期：20XX年10月10日