选择正确的降脂治疗方案PPT课件.ppt 32页

' ConsiderDrugRiskCategoryLDL-CGoalTherapyCHDorCHDriskequivalent<100mg/dL130mg/dL*2RiskFactors10-yrrisk10–20%<130mg/dL130mg/dL10-yrrisk<10%<130mg/dL160mg/dL<2RiskFactors<160mg/dL190mg/dL*100–129mg/dL=afterTLC,considerstatin,niacin,orfibratetherapyExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA2001;285:2486-2497. ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA2001;285:2486-2497. LDL DailyDoseAtorvaFluvaLovaPravaSimva10mg–39%–22%–30%20mg–43%–22%–27%–32%–38%40mg–50%–25%–32%–34%–41%80mg–60%–36%–42%–47%Physician’sDeskReference.55thed.Montvale,NJ:MedicalEconomics,2001. Lova20mg1%–9%–32%Prava10mg6%–11%–22%Simva10mg1%–20%–28%SteinEAetal.AmJCardiol1998;81:66B-69B. TrialDrugCHDRiskReductionPrimaryPreventionAFCAPS/TexCAPSLovastatin–40%*WOSCOPSPravastatin–31%*SecondaryPrevention4SSimvastatin–34%*CAREPravastatin–24%*LIPIDPravastatin–24%*IschemiaMIRACLAtorvastatin–26%**AVERTAtorvastatin–36%***NonfatalMIorCHDdeath;**ischemiceventsDownsJRetal.JAMA1998;279:1615-1622.|ShepherdJetal.NEnglJMed1999;333:1301-1307.|ScandinavianSimvastatinStudyGroup.Lancet1994;344:1383-1389.|SacksFMetal.NEnglJMed1996;335:1001-1009.|LIPIDStudyGroup.NEnglJMed1998;339:1349-1357.|SchwartzGGetal.JAMA2001;285:1711-1718.|PittBetal.NEnglJMed1999;341:70-76. +200–5–10–15–20–25–30–35–40–45–50MajorcoronaryeventsCoronarydeathsCardiovasculardeathsNoncardiovasculareventsTotalmortalityStrokesIntermittentclaudicationAnginaLaRosaJCetal.JAMA1999;282:2340-2346.|CrouseJRIIIetal.ArchInternMed1997;157:1305-1310.|PedersenTRetal.AmJCardiol1998;81:333-335. *Timecourseestablished nCommonsideeffectsnHeadache–Myalgia–FatiguenGIintolerance–Flu-likesymptomsnIncreaseinliverenzymesnOccursin0.5to2.5%ofcasesindose-dependentmannernSeriousliverproblemsareexceedinglyrarenManagebyreducingstatindoseordiscontinueuntillevelsreturntonormalnMyopathynOccursin0.2to0.4%ofpatientsnRarecasesofrhabdomyolysisnReducebynCautiouslyusingstatinsinpatientswithimpairedrenalfunctionnUsingthelowesteffectivedosenCautiouslycombiningstatinswithfibratesnAvoidingdruginteractionsnCarefulmonitoringofsymptomsnPresenceofmuscletoxicityrequiresthediscontinuationofthestatin 0%-5%-10%-15%-20%DavidsonMHetal.ExpertOpinInvestigDrugs2000;9:2663-2671.ReprintedwithpermissionfromAshleyPublications. VLDLVLDLLDL 35%25%12.5%Baseline-15%-30%01g/d2g/d3g/dAdaptedfromKnoppRH.NEnglJMed1999;341:498-511.1999MassachusettsMedicalSociety.Allrightsreserved. ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA2001;285:2486-2497. 0%-10%-20%-30%-40%-50%KnappHHetal.AmJMed2001;110:352-360.ReprintedwithpermissionfromExcerptaMedicaInc. 30%30%20%20%10%10%0%0%-10%-10%-20%-20%-30%-30%-40%WolfeMLetal.AmJCardiol2001;87:476-479. Baseline8months(mg/dL)(mg/dL)Change(%)LDL-C21585–60%HDL-C465213%LDL-C/HDL-C4.81.7–65%ratioBrownBGetal.AmJCardiol1997;80:111-115. LDL-CtargetNon-HDL-CPatientCategory(mg/dL)target(mg/dL)NoCHD,<2RF<160<190NoCHD,2+RF<130<160CHDorCHDrisk<100<130equivalentExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA2001;285:2486-2497. ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA2001;285:2486-2497. 20AtorvastatinFluvastatinLovastatinPravastatinSimvastatin(n=1,888)(n=474)(n=472)(n=461)(n=462)100-10-20-30-40LDL-CNon-HDL-C-50BallantyneCMetal.AmJCardiol2001;88:265-269. 20100-10-20-30-40-50DavignonJetal.AmJCardiol1994;73:339-345. Indications:AdjunctivetherapytodietHypertriglyceridemia(TypeIVandV)WithstatinsorotherLDL-C–loweringdrugsinmixedhyperlipidemiaEfficacy:DecreaseTG30–40%LDL-CremainsthesameorincreasesNochangeinHDL-CSideEffects:GIupsetanda“fishburp”InterventionLyonHeartStudy(dietary),GISSITrials:PrevenzioneTrial,others Indications:AdjunctivetherapytodietHypertriglyceridemia(TypeIVandV)Combinedhyperlipidemia(TypeIIb)withlowHDL-CwhodonotrespondtonicotinicacidMechanismofAction:IncreaseperipherallipolysisanddecreasehepaticTGproductionEfficacy:DecreaseTG25–50%LDL-Cdecreases,remainsthesame,orincreasesIncreaseHDL-C15–25%inhypertriglyceridemiaSideEffects:GIupset(8%),cholelithiasis,myositis,abnLFTsContraindications:HepaticorrenaldysfunctionPre-existinggallbladderdiseaseInterventionTrials:HHS,VA-HIT,BIP,LOCAT,BECAIT,DAIS HypercholesterolemiaMixedHPL(%)(%)FenoPlbFenoPlbn=92n=88n=24n=22TotalCholesterol–17.5–0.4–15.8+4.6LDL-C–20.3+0.4–6.1–0.5HDL-C+11.1–1.2+15.3–3.5TotalTriglycerides–37.9–4.2–44.6+22.3LDL-C/HDL-C–27.1–1.9–13.30.0VLDL-C–38.4–2.5–52.7+8.4p<0.01exceptforLDL-CinTypeIIb,wherep>0.10BrownWVetal.Arteriosclerosis1986;6:670-678.1999LippincottWilliams&Wilkins.www.lww.com 30Rx25Placebo20151050*PosthocanalysisofsubgroupwithTG>200mg/dLandHDL-C<42mg/dL.**PosthocanalysisofsubgroupwithTG200mg/dLandHDL-C<35mg/dL.***DifferencebetweenplaceboandRxforprimaryendpointwasstatisticallysignificant(p<0.05).FrickMHetal.NEnglJMed1987;317:1237-1245.|ManninenVetal.Circulation1992;85:37-45.|BIPStudyGroup.Circulation2000;102:21-27.|RubinsHBetal.NEnglJMed1999;341:410-418. 3020HDL-C10HDL-C0-10LDL-C-20LDL-CTGTG-30-40-50-60DaColPGetal.CurrTherResClinExp1973;53:473-482.|EllenRLetal.AmJCardiol1998;81:60B-65B. 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