老年人降低低密度脂蛋白膽固醇可顯著減少心血管事件
作者：
小柯機器人發布時間：2020/11/15 0:50:29
美國哈佛醫學院Marc S Sabatine團隊研究了降低老年患者低密度脂蛋白膽固醇的療效與安全性。2020年11月10日，該研究發表在《柳葉刀》雜誌上。
降低低密度脂蛋白（LDL）膽固醇來治療老年患者的臨床療效仍在爭論。為了總結老年患者LDL膽固醇降低治療的效果，研究組檢索了MEDLINE和Embase資料庫在2015年3月1日至2020年8月14日期間發表的文章，並進行系統回顧和薈萃分析。納入2018年美國心臟病學會和美國心臟協會指南推薦的一種LDL膽固醇降低藥物心血管結局的隨機對照試驗，平均隨訪時間至少為2年，並收集老年患者（年齡≥75歲）的數據。
研究組共確定了6篇文章，其中包括24項膽固醇治療試驗專家合作的薈萃分析和5項個體試驗。29項臨床試驗的244090例患者中，年齡≥75歲的有21 492例（8.8%），其中11750例（54.7%）來自他汀類試驗，6209例（28.9%）來自依澤替米貝試驗，3533例（16.4%）來自PCSK9抑制劑試驗。
中位隨訪時間為2.2-6.0年。降低LDL膽固醇可顯著降低老年患者發生重大心血管事件的風險，LDL膽固醇每降低1 mmol/L，風險降低26%（減少3519人），但與75歲以下患者的風險降低無統計學意義。在老年患者中，他汀類藥物和非他汀類藥物的風險比無統計學差異。老年人降低LDL膽固醇獲益較多，其中心血管死亡的風險比為0.85，心肌梗死為0.80，中風為0.73，冠狀動脈血運重建為0.80。
研究結果表明，對於75歲以上的患者中，降脂可顯著減少心血管事件。
附：英文原文
Title: Efficacy and safety of lowering LDL cholesterol in older patients: a systematic review and meta-analysis of randomised controlled trials
Author: Baris Gencer, Nicholas A Marston, KyungAh Im, Christopher P Cannon, Peter Sever, Anthony Keech, Eugene Braunwald, Robert P Giugliano, Marc S Sabatine
Issue&Volume: 2020-11-10
Abstract:
Background
The clinical benefit of LDL cholesterol lowering treatment in older patients remains debated. We aimed to summarise the evidence of LDL cholesterol lowering therapies in older patients.
Methods
In this systematic review and meta-analysis, we searched MEDLINE and Embase for articles published between March 1, 2015, and Aug 14, 2020, without any language restrictions. We included randomised controlled trials of cardiovascular outcomes of an LDL cholesterol-lowering drug recommended by the 2018 American College of Cardiology and American Heart Association guidelines, with a median follow-up of at least 2 years and data on older patients (aged ≥75 years). We excluded trials that exclusively enrolled participants with heart failure or on dialysis because guidelines do not recommend lipid-lowering therapy in such patients who do not have another indication. We extracted data for older patients using a standardised data form for aggregated study-level data. We meta-analysed the risk ratio (RR) for major vascular events (a composite of cardiovascular death, myocardial infarction or other acute coronary syndrome, stroke, or coronary revascularisation) per 1 mmol/L reduction in LDL cholesterol.
Findings
Data from six articles were included in the systematic review and meta-analysis, which included 24 trials from the Cholesterol Treatment Trialists' Collaboration meta-analysis plus five individual trials. Among 244090 patients from 29 trials, 21492 (8·8%) were aged at least 75 years, of whom 11750 (54·7%) were from statin trials, 6209 (28·9%) from ezetimibe trials, and 3533 (16·4%) from PCSK9 inhibitor trials. Median follow-up ranged from 2·2 years to 6·0 years. LDL cholesterol lowering significantly reduced the risk of major vascular events (n=3519) in older patients by 26% per 1 mmol/L reduction in LDL cholesterol (RR 0·74 [95% CI 0·61–0·89]; p=0·0019), with no statistically significant difference with the risk reduction in patients younger than 75 years (0·85 [0·78–0·92]; p interaction=0·37). Among older patients, RRs were not statistically different for statin (0·82 [0·73–0·91]) and non-statin treatment (0·67 [0·47–0·95]; p interaction=0·64). The benefit of LDL cholesterol lowering in older patients was observed for each component of the composite, including cardiovascular death (0·85 [0·74–0·98]), myocardial infarction (0·80 [0·71–0·90]), stroke (0·73 [0·61–0·87]), and coronary revascularisation (0·80 [0·66–0·96]).
Interpretation
In patients aged 75 years and older, lipid lowering was as effective in reducing cardiovascular events as it was in patients younger than 75 years. These results should strengthen guideline recommendations for the use of lipid-lowering therapies, including non-statin treatment, in older patients.
DOI: 10.1016/S0140-6736(20)32332-1
Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32332-1/fulltext