近期臨床試驗(yàn)對(duì)ATP-III的啟示課件

1、Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III GuidelinesScott M. Grundy; James I. Cleeman; C. Noel Bairey Merz; H. Bryan Brewer, Jr.; Luther T. Clark; Donald B. Hunninghake; Richard C. Pasternak; Sidney C. Smith, Jr.; Neil J. Stone; f

2、or the Coordinating Committee of the National Cholesterol Education ProgramThe Adult Treatment Panel (ATP III) of theNational Cholesterol Education Program issued an evidence-based set of guidelines on cholesterol management in 2001Implications of Recent Clinical Trials for the NCEP ATP III Guidelin

3、esBackgroundGrundy, S. et al., Circulation 2004;110:227-39.Since the publication of ATP III, 5 major clinical trials of statin therapy with clinical end points have been publishedThese trials addressed issues that were not examined in previous clinical trials of cholesterol-lowering therapyBackgroun

4、dGrundy, S. et al., Circulation 2004;110:227-39.Implications of Recent Clinical Trials for the NCEP ATP III GuidelinesTo review the results of these recent trials and assess their implications for cholesterol managementObjectiveGrundy, S. et al., Circulation 2004;110:227-39.Implications of Recent Cl

5、inical Trials for the NCEP ATP III GuidelinesLog-Linear Relationship Between LDL-C Levels and Relative Risk for CHD3.72.92.21.71.31.040 70 100 130 160 190Relative Risk for Coronary Heart Disease (Log Scale)LDL-Cholesterol (mg/dL)Grundy, S. et al., Circulation 2004;110:227-39.DrugDose, mg/dLDL Reduct

6、ion, %Atorvastatin10 39Lovastatin40 31Pravastatin40 34Simvastatin20-40 35-41Fluvastatin40-8025-35Rosuvastatin5-10 39-45Doses of Currently Available Statins Required to Attain an Approximate 30% to 40% Reduction of LDL-C Levels (Standard Doses)Grundy, S. et al., Circulation 2004;110:227-39. All of th

7、ese are available at doses up to 80 mg. For every doubling of the dose above the standard dose, an approximate 6% decrease in LDL-C level can be obtained. For rosuvastatin, doses available up to 40 mg; the efficacy for 5 mg is estimated by subtracting 6% from the FDA reported efficacy at 10 mgRisk C

8、ategoryLDL-C GoalInitiate TLCConsider Drug TherapyHigh risk: CHD or CHD risk equivalents (10-year risk 20%)100 mg/dL (optional goal: 70 mg/dL)100 mg/dL100 mg/dL (100 mg/dL: consider drug options)Moderately high risk: 2+ risk factors (10-year risk 10% to 20%)130 mg/dL130 mg/dL130 mg/dL (100-129 mg/dL

9、: consider drug options)Moderate risk: 2+ risk factors (10 year risk 10%)130 mg/dL130 mg/dL160 mg/dLLower risk: 0-1 risk factor160 mg/dL160 mg/dL190 mg/dL (160-189 mg/dL: LDL-lowering drug optional)ATP III LDL-C Goals and Cutpoints for TLC and Drug Therapy in Different Risk Categories and Proposed M

10、odifications Based on Recent Clinical Trial EvidenceGrundy, S. et al., Circulation 2004;110:227-39.Therapeutic lifestyle changes (TLC) remain an essential modality in clinical managementTLC have the potential to reduce CV risk through several mechanisms beyond LDL loweringRecommendations for Modific

11、ations to Footnotethe ATP III Treatment Algorithm for LDL-CGrundy, S. et al., Circulation 2004;110:227-39.Overview of RecommendationsRecommended LDL-C goal is 100 mg/dLAn LDL-C goal of 70 mg/dL is a therapeutic option on the basis of available clinical trial evidence, especially for patients at very

12、 high riskIf LDL-C is 100 mg/dL, an LDL-lowering drug is indicated simultaneously withlifestyle changesGrundy, S. et al., Circulation 2004;110:227-39.High-Risk PersonsRecommendations for Modifications to Footnotethe ATP III Treatment Algorithm for LDL-CRecommended LDL-C goal is 100 mg/dLIf baseline

13、LDL-C is 100 mg/dL, institution of an LDL-lowering drug to achieve an LDL-C level 70 mg/dL is a therapeutic option on the basis of available clinical trial evidenceGrundy, S. et al., Circulation 2004;110:227-39.High-Risk PersonsRecommendations for Modifications to Footnotethe ATP III Treatment Algor

14、ithm for LDL-CRecommended LDL-C goal is 100 mg/dLIf a high-risk person has high triglycerides or low HDL-C, consideration can be given to combining a fibrate or nicotinic acid with an LDL-lowering drugWhen triglycerides are 200 mg/dL, non-HDL-C is a secondary target of therapy, with a goal 30 mg/dL

15、higher than the identified LDL-C goalGrundy, S. et al., Circulation 2004;110:227-39.High-Risk PersonsRecommendations for Modifications to Footnotethe ATP III Treatment Algorithm for LDL-CRecommended LDL-C goal is 130 mg/dLAn LDL-C goal 100 mg/dL is a therapeutic option on the basis of available clin

16、ical trial evidenceGrundy, S. et al., Circulation 2004;110:227-39.Moderately High-Risk PersonsRecommendations for Modifications to Footnotethe ATP III Treatment Algorithm for LDL-CRecommended LDL-C goal is 100 mg/dLWhen LDL-C level is 100 to 129 mg/dL, at baseline or on lifestyle therapy, initiation

17、 of an LDL-lowering drug to achieve an LDL-C level 100 mg/dL is a therapeutic option on the basis of available clinical trial evidenceGrundy, S. et al., Circulation 2004;110:227-39.Moderately High-Risk PersonsRecommendations for Modifications to Footnotethe ATP III Treatment Algorithm for LDL-CAny p

18、erson at high risk or moderately high risk who has lifestyle-related risk factors (e.g., obesity, physical inactivity, elevated triglyceride, low HDL-C, or metabolic syndrome) is a candidate for TLC to modify these risk factors regardless of LDL-C levelGrundy, S. et al., Circulation 2004;110:227-39.High Risk/Moderately High-Risk PersonsRecommendations for Modifications to Footnotethe ATP III Treatment Algorithm for LDL-CWhen LDL-lowering drug therapy is employed in high-risk or moderately