中国成人血脂异常诊断和危险分层方案的研究

Cut offs and risk stratification of dyslipidemia in Chinese adults

目的为配合制订《中国成人血脂异常防治指南》,提出适合我国人群疾病和危险因素特点的血脂异常诊断界值和以血脂异常为基础的危险分层方案建议,以期更好地指导我国的血脂异常防治工作。方法汇总"中美心肺疾病流行病学合作研究"和"中国多省市心血管病队列研究"资料(基线入组共计40719人,年龄35～64岁,男女约各半,随访总计345 140.5人年),用统一的分析方案分析血脂异常与缺血性心血管病发病(ICVD,包括冠心病事件和缺血性脑卒中事件)的关系。相对危险的估计采用多元 Cox 比例风险模型,并控制其他危险因素。采用该模型计算不同危险因素组合时一个50岁的人今后10年发生缺血性心血管病的绝对危险,用于确定危险分层方案。结果两队列均呈现如下规律:(1)TC 和 LDL-C 水平与 ICVD 发病危险的关系是连续性的,并无明显的拐点;(2)LDL-C<3.37 mmo]/L(130 mg/dl)与 TC<5.18 mmol/L(200 mg/dl)的发病率(绝对危险)基本接近,而 LDL-C<4.14 mmol/L(160 mg/dl)与 TC<6.22 mmol/L(240 mg/dl)的发病率基本接近;(3)TC<5.18 mmol/L(200 mg/dl)时的绝对危险略高于理想血压[<120/80 mm Hg(1 mm Hg=0.133 kPa)]时的绝对危险,TC≥6.22 mmol/L(240 mg/dl)时的绝对危险略低于高血压1级的绝对危险;(4)随着HDL-C 水平的降低,ICVD 发病危险增加;(5)TG 与 ICVD 发病危险间未见显著关联;(6)在任一 TC水平,仅合并高血压时 ICVD 发病的绝对危险已高于合并3个其他危险因素时 ICVD 发病的绝对危险。结论我国人群血脂异常诊断标准可准确定为:TC<5.18 mmol/L(200 mg/dl)或 LDL-C<3.37mmol/L(130 mg/dl)为合适范围,TC 5.18～6.19 mmol/L(200～239 mg/dl)或 LDL-C 3.37～4.12mmol/L(130～159 mg/dl)为边缘升高,TC≥6.22 mmol/L(240 mg/dl)或 LDL-C≥4.14 mmol/L(160mg/dl)为升高。HDL-C<1.04 mmol/L(40 mg/dl)为减低,1.04～1.53 mmoL/L(40～59 mg/dl)为正常,≥1.55 mmol/L(60 mg/dl)为理想水平。此标准与国际相关标准一致。在危险分层方案中高血压的作用相当于其他任意3个危险因素的作用之和。

Objective To establish cut offs and risk stratification of dyslipidemia in Chinese adults. Methods Data from 2 widely cited studies： the PRC-US Collaborative Study of Cardiovascular and Cardiopulmonary Epidemiology and the China Multi-Provincial Cardiovascular Cohort Study, with a total of 40 719 Chinese adults, age 35 to 64 at baseline, about half men and half women, followed up for a total of 345 140. 5 person years, were used to analyze the relationship between dyslipidemia and ischemic cardiovascular diseases （ ICVD, including coronary heart events and isehemic stroke events） using a common data analysis protocol co-developed by the scientists from the 2 studies. The relative risk was estimated with the Cox proportional hazard model adjusting for other conventional cardiovascular risk factors. The 10-year absolute risk of ICVD for a 50 years-old person at different risk factor combinations was used to develop the risk stratification. Results （1） There was a continuous linear relationship between baseline TC （or LDL- C） and ICVD risk without a threshold; （2） The incidence （absolute risk） of ICVD was similar for LDL-C 〈 3. 37 mmol/L（130 mg/dl） and for TC 〈5. 18 mmol/L（200 mg/dl） ; and similar for LDL-C 〈4. 14 mmol/L （160 mg/dl） and for TC 〈6. 22 mmol/L（240 mg/dl） ; （3） The absolute ICVD risk for TC≥6. 22 mmol/L （240 mg/dl） was slightly less but close to that for grade 1 hypertension; （4） ICVD risk increased as HDL-C decreased; （5） No significant association was found between baseline TG and subsequent ICVD; （6） At any TC level, the absolute ICVD risk for those having only hypertension was higher than that for those having 3 other risk factors. Conclusion The cut offs for diagnosis of dyslipidemia in Chinese adults can refer to those used in relevant international guidelines： TC 〈5.18 mmol/L（200 mg/dl） [ or LDL-C 〈 3.37 mmol/L（ 130 mg/dl） ] as normal, TC 5. 18 - 6. 19 mmol/L（200 - 239 mg/dl） [ or LDL-C 3.37 - 4. 12 retooL/L（130 -159 mg/dl）] as borderline high, and TC≥6. 22 mmoL/L（240 mg/dl） [or LDL-C≥ 4. 14 mmol/L（160 mg/dl） ] as high; HDL-C 〈1.04 mmol/L（40 mg/dl） as low, 1.04 -1.53 mmol/L （40-59 mg/dl） as normal and ≥ 1.55 mmol/L（60 mg/dl） as optimal. In risk stratification scheme, hypertension plays a role that equals to that of any other 3 risk factors.