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[ADA2014]新ACC/AHA血脂指南是否适用于糖尿病患者?
——美国科罗拉多大学Robert H. Eckel教授访谈
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作者:R.H.Eckel 2014/6/15 17:20:00    加入收藏
内容概要:当地时间6月17日,第74届美国糖尿病协会(ADA)年会将举行一场有关“新ACC/AHA血脂指南是否适用于2型糖尿病患者?”的专题辩论研讨会。

 

   <International Diabetes> : Dr. Eckel, the ACC/AHA guidelines have expanded their indications for lipid lowering drug statin therapy to prevent cardiovascular disease. I know you were a strong voice in supporting this.  Can you share with us your reason for supporting that decision?

  Dr. Eckel : Right the task at hand initially was to update the cholesterol guidelines for cardiovascular disease risk reduction.  This started as a government operation through The National Heart, Lung, and Blood Institute and was picked up at the very end by the American College of Cardiology and the American Heart Association.  That transition took place because the government had decided near the terminus of this whole project that they were no longer going to support guidelines. What we had done at the NIH ultimately transitioned to the ACC and the AHA.
  What we defined was first of all that a heart healthy lifestyle was important to prevent cardiovascular disease.  I co-chaired the lifestyle workgroup and that relates to nutrition, that relates to physical activity, and of course smoking should never be present in people who have heart disease and who are at risk.  Through that process we really emphasized dietary patterns and dietary patterns can be applied ethically, culturally, and in many other ways.  Basically these are diets that are high in fruits and vegetables and whole grains, and enriched in fish.  A healthy lifestyle in terms of physical activity is 30 to 40 minutes of moderately vigorous activity 3 to 4 days a week. Keep in mind that whole lifestyle guideline played into the cholesterol guideline because we know that these types of lifestyle maneuvers relate to a reduced level of blood pressure and LDL cholesterol.
  What we decided in our evidence based review that really reviewed randomized controlled trials only that met certain inclusion and exclusion criteria that basically there are 4 groups of patients who should be treated with statins.  This is true not only for coronary heart disease risk reduction but also for stroke.
  The four groups are people with existing atherosclerotic cardiovascular disease, stroke, or myocardial infarction or periphery vascular disease.  In the second group are patients who have a very high LDL cholesterol aged 21 or higher, so with LDLs above 190 mg/dL, those patients should consider treatment.  Both of those first two groups, people with known atherosclerotic disease and who have high LDL cholesterol should be treated with high dose statins, either the penultimate or ultimate dose.
  The third group is patients with diabetes.  Here the guideline is a little bit different in that the guideline for diabetes relates to the clinical trials where there was insufficient evidence to say that this treatment paradigm worked with patients with diabetes.  Patients with diabetes between the ages of 40 and 75, and because the clinical trials did not have that much data on a very high dose of statins, those trials really looked at moderate dose statin therapy as the recommendation.
  Then the fourth group where patients who did not have diabetes who were being assessed by a risk estimator in terms of their cardiovascular disease risk.  Diabetes patients, who may not have met the criteria for their diabetes group, in other words let us take a 42 year old patient with type 2 diabetes who has no risk factors.  He or she may not have met criteria for statin therapy based on their overall risk assessment but when you insert them into the risk estimator, the fourth group may have had enough weight from having diabetes to be pushed into a statin treatment group. In that fourth group those are people without known disease who have risk factors for cardiovascular disease that are predicted by the risk estimator.  The risk estimator is downloadable on a portable device or it can be done online.  These are people who have a greater than 7.5% risk of having a stroke or coronary event over the next 10 years.  That is the way we define primary prevention and almost all patients with diabetes will fall into the third category, between 40 and 75, but if the clinician feels that their patient will not really have that much risk other than having new onset diabetes, they can be put into the risk estimator to determine their 10 year risk.
 
  《国际糖尿病》:ACC/AHA指南扩大了他汀类降脂药物治疗预防心血管疾病的适应证。据我们所知,您对此持支持态度。能否请您与我们分享一下您支持此推荐的原因?
  Eckel 教授:发布该指南的最初目的是更新降低心血管疾病风险的胆固醇指南。一开始的时候,这项任务是由美国国家心、肺及血压研究所(NIH)进行官方运作的,最终移交美国心脏病学学会(ACC)及美国心脏协会(AHA)由其来共同通过和发布。之所以发生了这样的移交是因为美国政府决定终止整个项目不再以官方身份支持和进行指南制定发布。我们在NIH负责期间所做的工作最终被全部移交给了ACC和AHA。
  首先,指南明确指出,对心脏健康有益的生活方式对心血管疾病预防的重要性。我是编写生活方式部分的联合主席,在该部分中指南强调,健康生活方式涉及营养、体力活动、吸烟等方面的内容。对已有心脏疾病及心血管疾病高危人群而言,是绝对不能吸烟的。同时,指南关注和强调饮食习惯或膳食结构的作用,倡导富含水果、蔬菜、粗粮及各种鱼类的饮食。就体力活动而言,健康的生活方式强调每周要进行3~4天,每天30~40分钟的中等程度的体育运动。我们需要牢记生活方式指南在胆固醇指南中是不可或缺的,因为这些健康生活方式有助于降低血压及LDL-C水平。
  我们进行了以循证为基础的证据审查,在对符合特定入选标准及排除标准的随机对照试验进行全面审查后,确定了四类应接受他汀治疗的患者。这些患者可从他汀治疗中明确获益,他汀治疗不仅能降低其冠心病发生风险,还能降低其卒中发生风险。
  这四类人群的第一组人群是,伴有、卒中、心肌梗死或外周血管疾病等已知动脉粥样硬化性心血管疾病的患者;第二组人群是LDL-C极高的年龄≥21岁的成人(LDL-C>190 mg/dl[4.9 mmol/L]时应考虑他汀治疗)。伴有已知动脉粥样硬化性疾病及LDL-C水平非常高的人群均应采用高剂量他汀进行治疗。第三类人群是年龄在40~75岁的糖尿病患者(此处与糖尿病指南认为“临床试验无充分证据表明他汀降脂治疗对糖尿病患者有益”不同)。指南认为,鉴于目前临床试验尚无高剂量他汀应用于糖尿病患者的大量证据,故推荐采用中等剂量他汀治疗。
  第四组人群是无糖尿病但心血管风险计算工具评估结果显示存在较高心血管疾病发生风险的患者。对不符合糖尿病组人群标准的糖尿病患者,根据其总体风险评估结果而言可能并不满足他汀起始治疗标准,但是采用风险计算工具其可能将被划为第四类人群,需要接受他汀治疗。第四组获益人群是没有已知疾病但伴有心血管疾病危险因素、心血管风险计算器显示未来卒中或冠状动脉事件等心血管疾病发生风险>7.5%的患者。指南推荐的风险计算工具可通过便携设备或在线下载。
  通过上述对获益人群的明确定义,指南确定了他汀一级预防的人群。几乎所有的年龄40~75岁的糖尿病患者均可被纳入至第三组,如果医生感觉自己的患者除了新发糖尿病外真的并无其他心血管危险因素,则可以采用风险计算工具评估其未来十年心血管风险。
 


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