比较3种不同指南/共识评价极高风险或超高危动脉粥样硬化性心血管疾病危险分层和血脂达标率差异

Risk stratification and low-density lipoprotein cholesterol goal attainment rates in patients with very high-risk or extreme high-risk atherosclerotic cardiovascular diseases regarding three guidelines

目的探索3种不同标准对同一动脉粥样硬化性心血管疾病(ASCVD)队列极高风险或超高危的危险分层及低密度脂蛋白胆固醇(LDL-C)达标率的差异,并分析差异的主要来源。方法连续入选2019年1—12月在首都医科大学附属北京安贞医院心内科行冠状动脉造影的ASCVD患者,分别应用2018美国胆固醇管理指南(简称2018指南)、2019中国胆固醇教育计划调脂治疗专家建议(简称2019建议)和2020超高危ASCVD患者血脂管理中国专家共识(简称2020共识)评估极高风险或超高危ASCVD患者比例,LDL-C绝对值达标率的差异,以及导致差异的来源。结果研究共纳入患者1864例,根据2018指南、2019建议、2020共识,极高风险或超高危ASCVD比例分别为59.4%、90.7%和65.6%;LDL-C绝对值达标率分别为37.2%、15.7%和13.7%,两两之间差异均有统计学意义(P值均<0.001)。2020共识与2018指南达标率的差异61.5%缘于LDL-C目标值不同,38.5%缘于危险分层差异;2020共识与2019建议达标率的差异仅13.2%缘于LDL-C目标值不同,86.8%缘于危险分层差异。结论3种极高风险或超高危ASCVD标准在同一队列中占比及LDL-C达标率差异显著。2020共识超高危人群比例适中,LDL-C达标率最低。2020共识与2018指南的差异主要缘于LDL-C目标值不同,与2019建议的差异主要缘于危险分层差异。

Objective To explore the differences of risk stratification of very high-risk or extreme high-risk atherosclerotic cardiovascular diseases(ASCVD)and the attainment rates of low-density lipoprotein cholesterol(LDL-C)management targets evaluated by three different criteria,and the causal attributions of these differences.Methods Patients with ASCVD were consecutively enrolled from January 1 to December 31 in 2019,and were evaluated for very high-risk or extreme high-risk and LDL-C goal attainment rates with 2018 American guideline on the management of blood cholesterol(2018AG),2019 China Cholesterol Education Program(CCEP)Expert Advice for the management of dyslipidemias(2019EA)and 2020 Chinese expert consensus on lipid management of very high-risk ASCVD patients(2020EC),respectively.The causal attributions of the differences in attainment rates were analyzed as well.Results A total of 1864 ASCVD patients were included in this study.According to 2018AG,2019EA and 2020EC,the proportions of the patients with very high-risk or extreme high-risk were 59.4%,90.7%,and 65.6%,respectively.The absolute LDL-C target attainment rates were 37.2%,15.7%,and 13.7%,respectively,the differences between each two rates were statistically significant(all P<0.001).As to the differences in attainment rates between 2020EC and 2018AG,61.5%were due to the different LDL-C goal attainment values and 38.5%were caused by the different risk stratifications,while for the differences between 2020EC and 2019EA attainment rates,different LDL-C goal attainment values were responsible for 13.2%,and different risk stratifications were responsible for 86.8%of the differences.Conclusions There are significant differences in the proportions and LDL-C attainment rates among the three different criteria for very high-risk or extreme high-risk ASCVD.2020EC showed a moderate proportion of patients with extreme high-risk,and had the lowest LDL-C attainment rate.The differences between 2020EC and 2018AG are mainly due to the LDL-C target values,and the differences between 2020EC and 2019EA are mainly caused by the risk stratifications.