超高危ASCVD患者的界定标准对住院ACS患者降脂治疗需求的影响

The expanding needs on lipid-lowering treatment in patients with acute coronary syndrome by applying newly issued definition of extreme high-risk by Chinese Society of Cardiology

目的评价采用中华医学会心血管病学分会(CSC)《超高危动脉粥样硬化性心血管疾病患者血脂管理中国专家共识》提出的超高危界定标准对住院急性冠状动脉综合征(ACS)患者降脂治疗需求的影响。方法本研究基于CSC和美国心脏病协会(AHA)合作的中国心血管疾病医疗质量改善项目。该项目是一项基于病例的注册登记研究,在全国158家三级医院和82家二级医院连续入选住院ACS患者,系统地收集患者的临床相关信息。本研究纳入该项目2014年11月至2019年7月入选的所有ACS患者,分析超高危ACS患者的比例和特征,入院时低密度脂蛋白胆固醇(LDL-C)平均水平和距离新LDL-C目标值的差距,以及出院时患者接受降脂治疗的强度和联合用药的情况。结果共纳入104516例ACS住院患者,其中75.1%(78527/104516)的患者符合CSC专家共识提出的超高危动脉粥样硬化性心血管病(ASCVD)的标准,需要达到新的LDL-C目标。在超高危患者中,21.2%(16651/78527)的患者发生过≥2次严重ASCVD事件,78.8%(61876/78527)的患者发生过1次严重ASCVD事件合并≥2个高风险因素。超高危患者入院时LDL-C水平为(2.8±1.0)mmol/L,且93.4%(73307/78527)的患者入院时LDL-C水平≥1.4 mmol/L,未达到1.4 mmol/L目标值的患者LDL-C距目标值的中位距离为1.3(0.8,2.0)mmol/L。如果将患者入院时的LDL-C水平降低50%,预计有55.6%(43632/78527)的超高危患者LDL-C水平可以达标。在40875例收集了出院处方中他汀类药物及剂量信息的患者中,93.5%(28004/29947)的超高危患者出院时接受他汀类药物治疗,其中95.1%(26632/28004)的患者接受他汀单药治疗,91.1%(25501/28004)的患者接受中等强度治疗。结论约3/4的住院ACS患者属于超高危患者,9/10的患者入院时LDL-C水平高于新的LDL-C降脂目标,目前临床常规实施的降脂治疗措施和新的降脂治疗需求之间存在明显差距。

Objective To assess the expanding needs on lipid-lowering treatment in patients with acute coronary syndrome(ACS)by applying newly issued definition of extreme high-risk,which is proposed by Chinese expert consensus on lipid management of extreme high-risk atherosclerotic cardiovascular disease(ASCVD)patients of Chinese Society of Cardiology(CSC).Methods Data of this study was derived from the Improving Care for Cardiovascular Disease in China(CCC)project,which was a case-based nationwide registry study and launched as a collaborative initiative by the American Heart Association and the CSC.The project consecutively recruited ACS patients from158 tertiary hospitals and 82 second hospitals across China,and detailed clinical information of patients was collected.This study enrolled ACS inpatients in CCC project from November 2014 to July 2019.The proportion of extreme high-risk patients,their characteristics,mean LDL-C levels at admission,the gap between measured LDL-C level and the new target,and lipid-lowering therapy at discharge were assessed.Results Among 104516 ACS inpatients enrolled in this study,75.1%(78527/104516)met the criteria of extreme high-risk and were expected to achieve the new LDL-C goal.Among patients at extreme high-risk,21.2%(16651/78527)had multiple severe ASCVD events and 78.8%(61876/78527)had 1 severe ASCVD event and at least two high-risk factors.For the extreme high-risk patients,the mean level of LDL-C at admission was(2.8±1.0)mmol/L,prevalence of LDL-C≥1.4 mmol/L was 93.4%(73307/78527)and the median gap between LDL-C level at admission and the target of 1.4 mmol/L was 1.3(0.8,2.0)mmol/L.If LDL-C could be further reduced to 50% of the admission level,we estimated that 55.6%(43632/78527)of the extreme high-risk patients would achieve the new LDL-C goal.Among 40875 patients with information about discharge statin dosage,93.5%(28004/29947)of the extreme high-risk patients were prescribed with statins at discharge,and among them 95.1%(26632/28004)received statin monotherapy and 91.1%(25501/28004)were at moderate doses of statins.Conclusion About three fourth of inpatients with ACS were categorized as extreme high-risk based on the new definition of CSC expert consensuses,nine out of ten patients at extreme high-risk didn't achieve the new LDL-C target at admission,and the intensity of lipid-lowering therapy was insufficient in clinical practice.There are substantially expanding needs for implementing more intensive and effective lipid-lowering strategies.