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缺血性卒中后两个LDL胆固醇目标值的比较
A Comparison of Two LDL Cholesterol Targets after Ischemic Stroke


Pierre Amarenco ... 心脑血管疾病 • 2020.01.02
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缺血性卒中后的LDL胆固醇水平,底线在哪里

 

陈奕奕,王伊龙*

首都医科大学附属北京天坛医院神经内科

*通讯作者

 

血液中的高胆固醇浓度是包括卒中在内的心血管疾病的高危因素。因此,降低胆固醇的他汀类药物已广泛用于管理心血管疾病高危人群,临床试验也显示他汀类药物能够降低他们首发或再发的心血管事件。

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摘要


背景

应用他汀类药物的强化降脂治疗被推荐用于动脉粥样硬化引起的短暂性脑缺血发作(TIA)和缺血性卒中患者。旨在减少卒中后心血管事件的低密度脂蛋白(LDL)胆固醇目标水平尚未经过充分研究。

 

方法

在这项于法国和韩国开展的平行组试验中,我们将之前3个月内发生过缺血性卒中或之前15日内发生过TIA的患者随机分组,分别采用<70 mg/dL(1.8 mmol/L)的LDL胆固醇目标水平(低目标组)或90 mg/dL至110 mg/dL(2.3 mmol/L至2.8 mmol/L)的目标范围(高目标组)。所有患者均有脑血管或冠状动脉粥样硬化的证据,并接受了他汀类药物、依折麦布或这两种药物治疗。由主要心血管事件构成的复合主要终点包括缺血性卒中、心肌梗死、导致冠状动脉或颈动脉紧急血管重建的新发症状或心血管原因死亡。

 

结果

共计2,860例患者被纳入研究,并接受了中位3.5年随访;LDL胆固醇的高目标组和低目标组各分配了1,430例患者。基线时的平均LDL胆固醇水平为135 mg/dL(3.5 mmol/L),低目标组和高目标组达到的平均LDL胆固醇水平分别为65 mg/dL(1.7 mmol/L)和96 mg/dL(2.5 mmol/L)。本试验预计将发生385起终点事件,但发生277起终点事件后,试验因管理方面的原因终止。低目标组和高目标组分别有121例患者(8.5%)和156例患者(10.9%)发生了复合主要终点(校正的风险比,0.78;95% CI,0.61~0.98;P=0.04)。颅内出血和新诊断糖尿病的发生率无显著组间差异。

 

结论

有动脉粥样硬化证据的患者发生缺血性卒中或TIA后,LDL胆固醇目标水平<70 mg/dL的患者发生后续心血管事件的风险低于目标范围90 mg/dL至110 mg/dL的患者(由法国卫生部等资助;将卒中治疗至达到目标[Treat Stroke to Target]在ClinicalTrials.gov注册号为NCT01252875)。





作者信息

Pierre Amarenco, M.D., Jong S. Kim, M.D., Julien Labreuche, B.S.T., Hugo Charles, B.S.T., Jérémie Abtan, M.D., Yannick Béjot, M.D., Lucie Cabrejo, M.D., Jae-Kwan Cha, M.D., Grégory Ducrocq, M.D., Ph.D., Maurice Giroud, M.D., Celine Guidoux, M.D., Cristina Hobeanu, M.D., Yong-Jae Kim, M.D., Bertrand Lapergue, M.D., Ph.D., Philippa C. Lavallée, M.D., Byung-Chul Lee, M.D., Kyung-Bok Lee, M.D., Didier Leys, M.D., Marie-Hélène Mahagne, M.D., Elena Meseguer, M.D., Norbert Nighoghossian, M.D., Fernando Pico, M.D., Ph.D., Yves Samson, M.D., Igor Sibon, M.D., P. Gabriel Steg, M.D., Sang-Min Sung, M.D., Pierre-Jean Touboul, M.D., Emmanuel Touzé, M.D., Ph.D., Olivier Varenne, M.D., Ph.D., Éric Vicaut, M.D., Nessima Yelles, and Eric Bruckert, M.D. for the Treat Stroke to Target Investigators*
From the Department of Neurology and Stroke Center (P.A., J.L., H.C., L.C., C.G., C.H., P.C.L., E.M., P.-J.T.) and the Department of Cardiology (J.A., G.D., P.G.S.), Assistance Publique–Hôpitaux de Paris (APHP), Bichat Hospital, Laboratory for Vascular Translational Science, INSERM Unité 1148, Département Hospitalo Universitaire–Fibrose Inflammation Remodelage, and the Department of Cardiology, Cochin Hospital (O.V.), University of Paris, the Department of Neurology, Foch Hospital (B.L.), Urgences Cerebrovasculaires (Y.S.), Centre de Pharmacoépidémiologie de l’APHP (N.Y.), and the Department of Endocrinology (E.B.), Hôpital de la Pitié–Salpêtrière, the Department of Biostatistics, APHP, Université Paris Diderot, Sorbonne Paris Cité, Fernand Widal Hospital (É.V.), and the Department of Endocrinology, Sorbonne University (E.B.), Paris, Équipe d’Accueil EA2694, Santé Publique: Epidémiologie et Qualité des Soins (J.L.), and the Department of Neurology, Stroke Unit, University of Lille, Centre Hospitalier Universitaire (CHU) de Lille (D.L.), Lille, the Department of Neurology, University Hospital of Dijon, University of Burgundy, Dijon (Y.B., M.G.), the Stroke Unit, Pasteur Hospital, Nice (M.-H.M.), Hospices Civils de Lyon, Department of Neurology and Stroke Center, Lyon University, Lyon (N.N.), the Department of Neurology, Versailles University Hospital, Versailles (F.P.), the Department of Vascular Neurology, Pellegrin Tripode Hospital, University of Bordeaux, Bordeaux (I.S.), and the Department of Neurology, Université Caen Normandie, CHU Caen Normandie, INSERM Unité 1237, Cyceron, Caen (E.T.) — all in France; Asan Medical Center (J.S.K.), the Department of Neurology, Eunpyeong St. Mary’s Hospital, Catholic University of Korea (Y.-J.K.), and the Department of Neurology, Soonchunhyang University College of Medicine (K.-B.L.), Seoul, Dong-a University Hospital (J.-K.C.) and the Department of Neurology and Stroke Center, Pusan National University Hospital (S.M.S.), Busan, and the Department of Neurology, Hallym University Sacred Heart Hospital, Anyang (B.-C.L.) — all in South Korea; and the National Heart and Lung Institute–Imperial College and the Institute of Cardiovascular Medicine and Science–Royal Brompton Hospital, London (P.G.S.). Address reprint requests to Dr. Amarenco at the Department of Neurology and Stroke Center, Bichat Hospital, 46 rue Henri Huchard, Paris 75018, France, or at pierre.amarenco@aphp.fr. *A complete list of the Treat Stroke to Target investigators is provided in the Supplementary Appendix, available at NEJM.org.

 

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