≤45岁急性冠脉综合征患者可能家族性高胆固醇血症的临床特点及血脂达标影响因素研究

Familial Hypercholesterolemia in 45-year-old and Younger Patients with Acute Coronary Syndrome:Clinical Characteristics and Influencing Factors of Blood Lipid Control Effect

背景急性冠脉综合征(ACS)是临床的急危重症,近年来发病呈年轻化趋势,家族性高胆固醇血症(FH)是以早发动脉粥样硬化为特征的遗传性疾病,既往研究发现在年轻ACS患者中FH的检出率并不低,但对其降脂疗效随访的相关研究仍较少,同时≤45岁ACS患者血脂未达标的原因仍有待分析。目的研究≤45岁ACS患者中FH检出率及临床特点,并观察降脂疗效,对患者血脂未达标的危险因素进行分析。方法选取2019年10月至2021年10月于阜外华中心血管病医院住院治疗且可获取随访血脂记录的ACS患者为研究对象。通过电子病历系统收集患者临床资料,空腹8 h后采集静脉血进行实验室检查,采用Gensini积分系统评估冠状动脉病变严重程度,Gensini积分≥75%定义为冠脉严重狭窄。采用荷兰临床脂质网络(DLCN)评分诊断可能FH,并根据DLCN积分将研究对象分为可能FH组(n=57)和非FH组(n=223)。随访低密度脂蛋白胆固醇(LDL-C)观察降脂治疗的疗效,LDL-C<1.4 mmol/L认定为血脂达标。采用多因素Logistic回归分析探究降脂治疗后患者血脂达标的影响因素。结果本研究最终纳入280例患者,两组患者他汀治疗史、冠心病家族史、超高危冠心病比例、早发冠心病家族史、发病类型、总胆固醇、基线LDL-C、冠脉严重狭窄比例比较,差异有统计学意义(P<0.05)。可能FH组患者随访LDL-C、LDL-C变化量、LDL-C降幅高于非FH组,血脂达标率低于非FH组(P<0.05)。多因素Logistic回归分析结果显示,接受冠状动脉旁路移植术治疗〔OR=4.32,95%CI(1.21,15.42)〕、基线LDL-C水平升高〔OR=2.22,95%CI(1.62,3.03)〕是≤45岁ACS患者血脂达标的危险因素(P<0.05),应用他汀联合依洛尤单抗〔OR=0.10,95%CI(0.03,0.40)是≤45岁ACS患者血脂达标的保护因素(P<0.05)。结论≤45岁ACS患者中可能FH患者并不少见(20.36%),值得临床关注;可能FH组患者LDL-C降低幅度更大,但血脂达标率仍低于非FH组;在≤45岁ACS患者中,接受冠状动脉旁路移植术治疗和基线LDL-C水平较高的人群降脂达标率更低,应用他汀联合依洛尤单抗可以促使LDL-C达标。

Background Acute coronary syndrome(ACS)is an acute and critical disease,which has tended to occur in younger people in recent years.Familial hypercholesterolemia(FH)is a hereditary disease characterized by earlyonset atherosclerosis.Previous studies have found that the detection rate of FH in young ACS patients is not low,but there are still few studies on the follow-up of lipid-lowering efficacy.At the same time,the reasons of non-attainment for the LDL-C in≤45-year-old ACS patients remain to be analyzed.Objective To study the detection rate and clinical characteristics of FH in ACS patients aged≤45 years,and to observe the short-term lipid-lowering effect and analyze the risk factors for non-attainment of lipid targets.Methods ACS inpatients aged≤45 years with available follow-up blood lipid records were recruited from Fuwai Central China Cardiovascular Hospital from October 2019 to October 2021.Clinical data were collected through the electronic medical record system.Venous blood samples were collected for laboratory test after eight-hour fasting.Gensini score was used to evaluate the severity of coronary artery disease,Gensini score≥75%was defined as severe coronary artery stenosis.The Dutch Lipid Clinical Network(DLCN)criteria were used to diagnose FH.According to the DLCN score,the subjects were divided into possible FH group(n=57)and non-FH group(n=223).The low-density lipoprotein cholesterol(LDL-C)was followed up to observe the effect of lipid-lowering therapy.LDL-C<1.4 mmol/L was considered as blood lipid control.Multivariate Logistic regression analysis was used to analyze the factors affecting the attainment of LDL-C target level.Results In this study,280 patients were eventually enrolled.Statin treatment history,family history of coronary heart disease,proportion of high risk coronary heart disease,premature coronary heart disease,type of ACS,total cholesterol,baseline LDL-C and proportion of severe coronary artery stenosis were significantly different between the two groups(P<0.05).LDL-C in follow-up,LDL-C change,LDL-C reduction in FH group were higher than those in non-FH group,the rate of attain of blood lipif was lower than that in non-FH group(P<0.05).Multivaliate Logistic regression analysis showed that receiving coronary artery bypass grafting(CABG)treatment〔OR=4.32,95%CI(1.21,15.42)〕and elevated baseline LDL-C〔OR=2.22,95%CI(1.62,3.03)〕were risk factors for the attainment of blood lipid level(P<0.05),while statins combined with evolocumab〔OR=0.10,95%CI(0.03,0.40)〕was the protective factor(P<0.05).Conclusion The possible FH is not uncommon in ACS patients aged≤45 years(20.36%),and its detection rate increases in those also with acute myocardial infarction,which is worthy of clinical attention.The rate of attaining the target LDL-C level is still lower than that of non-FH group.And the rate of attaining the blood lipid level is even more lower in those receiving CABG treatment or with elevated baseline LDL-C level.The use of statins combined with evolocumab can increase the rate of attaining the target LDL-C level.