冠心病合并高血压患者降脂治疗现状及LDL-C达标的关联因素分析

Analysis of current status of lipid-lowering therapy and factors associated with low-density lipoprotein cholesterol goal attainment in patients with coronary heart disease combined with hypertension

目的:调查冠心病合并高血压患者降脂治疗现状,并探讨低密度脂蛋白胆固醇(LDL-C)达标的关联因素。方法:该研究为横断面研究。纳入2008年8月5日至2018年7月22日解放军总医院心内科住院的冠心病合并高血压患者,根据LDL-C是否达标,分为达标组和未达标组。研究数据来自解放军总医院心内科住院患者冠状动脉造影记录和电子病历数据库,多次住院的患者使用首次诊断为冠心病时的数据。收集入选患者的临床资料。采用多因素logistic回归模型分析冠心病合并高血压患者LDL-C达标的关联因素。结果:共入选患者18800例,来自我国31个省/自治区/直辖市,其中北京占比最高[5692例(30.28%)],其次为河北[3621例(19.26%)]、河南[1837例(9.77%)]、山东[1618(8.61%)]等。入选患者中,LDL-C<1.4 mmol/L者1493例(达标组),LDL-C≥1.4 mmol/L者17307例(未达标组)。入选患者中仅1493例(7.94%)LDL-C达标。LDL-C为1.4~<2.0、2.0~<2.5、2.5~<3.8和≥3.8 mmol/L的患者分别4518例(24.03%)、4366例(23.22%)、6924例(36.83%)和1499例(7.97%)。17885例(95.13%)患者已使用他汀类药物进行治疗,但联合应用他汀类药物和依折麦布降脂治疗者仅1334例(7.10%)。入选患者中心血管事件低危者4986例(26.52%)、中危者6515例(34.65%)、高危者7299例(38.82%)。中、高危患者中应用他汀类药物联合依折麦布进行降脂治疗者分别占7.43%(484/6515)、7.48%(546/7299)。多因素logistic回归分析结果显示年龄增大、男性、合并糖尿病、合并卒中、经皮冠状动脉介入治疗史与冠心病合并高血压患者LDL-C达标呈正向关联,而肥胖和急性心肌梗死则呈负向关联(均P<0.01)。结论:我国冠心病合并高血压患者LDL-C达标率较低,尽管大多数患者已接受了他汀类药物治疗,但联合接受依折麦布治疗者比例极低,在我国冠心病合并高血压患者中再发心血管事件中、高危患者的比例较高,而此类患者接受他汀类药物联合依折麦布进行降脂治疗的比例较低。本研究结果还显示年龄增大、男性以及合并糖尿病、卒中、经皮冠状动脉介入治疗史与冠心病合并高血压患者LDL-C达标呈独立正向关联,肥胖和急性心肌梗死则呈独立负向关联。

Objective To explore the current status of lipid-lowering therapy,the distribution of low-density lipoprotein cholesterol(LDL-C)levels and the risk assessment of cardiovascular events recurrence in patients with coronary heart disease(CHD)complicated by hypertension.Methods This was a cross-sectional study.Patients with CHD combined with hypertension were hospitalized in the Department of Cardiology,General Hospital of Chinese People′s Liberation Army from August 5,2008 to July 22,2018 were included,and were divided into standard group and substandard group according to whether LDL-C reached the standard.Study data were obtained from inpatient coronary angiography records and electronic medical records database of Department of Cardiology,General Hospital of Chinese People′s Liberation Army,who used data from the first diagnosis of CHD.Clinical data of the selected patients were collected.Multivariate logistic regression model was used to analyze the associated factors of whether LDL-C reached the standard in CHD patients with hypertension.Results A total of 18800 patients were selected from 31 provinces/autonomous regions/municipalities directly under the central government in China,with Beijing accounting for the largest proportion(5692 patients(30.28%)),followed by Hebei(3621 patients(19.26%)),Henan(1837 patients(9.77%)),and Shandong(1618 patients(8.61%)).Among the selected patients,1493 had LDL-C<1.4 mmol/L(standard group),and 17307 had LDL-C≥1.4 mmol/L(substandard group).Only 1493 patients(7.94%)had LDL-C<1.4 mmol/L.There were 4518 patients(24.03%),4366 patients(23.22%),6924 patients(36.83%)and 1499 patients(7.97%)with LDL-C for 1.4-<2.0,2.0-<2.5,2.5-<3.8 and≥3.8 mmol/L levels,respectively.17855 patients(95.15%)were treated with statins,but only 1334 patients(7.10%)were treated with statins and ezetimibe.Of the selected patients,4986 patients(26.52%)were at low risk,6515 patients(34.65%)were at intermediate risk,and 7299 patients(38.82%)were at high risk.The combined lipid-lowering treatment rates of statin and ezetimibe in the middle-and high-risk patients were 7.43%(484/6515)and 7.48%(546/7299),respectively.The results of multivariate logistic regression analysis showed that increasing age,male,diabetes mellitus,stroke,and history of percutaneous coronary intervention(PCI)were positively associated with LDL-C standards in patients with CHD and hypertension,whereas obesity and acute myocardial infarction(AMI)were negatively associated with LDL-C standards(all P<0.01).Conclusions The rate of achieving the standard LDL-C in patients with CHD combined with hypertension was low in China.Although the majority of patients had received moderate-intensity statin therapy,the proportion of statin-treated patients combined with ezetimibe was extremely low.The proportion of high-risk patients with recurrent cardiovascular events was higher in patients with CHD and hypertension in China,whereas the proportion of such patients receiving statin combined with ezetimibe lipid-lowering therapy was lower.This study also found that increasing age,male,diabetes mellitus,stroke,and history of PCI were positively associated with LDL-C standards,while obesity and AMI were negatively associated with LDL-C standards in patients with CHD and hypertension.