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1、,现代脂质三联治疗,执教教师：XXX,Introduction,Part I,Efficacy - The Power to Reach Target,Key Factor: + Differentiators: LDL Reduction TG HDL LDL/HDL Ratio The Lipid Triad,The LDL/HDL Ratio - Our Strength, Our Story!,A new perception of efficacy,LDL,HDL,Additional risk factor, especially in diabetics,The Lipid Tr
2、iad - Overview,TG,The Lipid Triad,The Ratio,The Lipid Triad and Strategic Rationale,Part II,No scientific evidence Evidence contradicting this statement A marketing hypothesis to build their LDL story Creating the perception of the statin with the strongest efficacy,The lower. .the better?,Its logic
3、al,Its measurable,Its practicable,The Lipid Triad - The GPs Perspective,HDL,LDL,Supporting Data from Landmark Studies,Part III,12 10 8 6 4 2 0,% Mortality,Placebo Q1 Q2 Q3 Q4 (low HDL-increase) (high HDL-increase),4S - Study,CAD Mortality per Quartiles of Increases in HDL-Cholesterol,KJEKSHUS J & PE
4、DERSEN T (unpublished),HDL Intervention Trial (VA-HIT),RUBINS HB et al. New Engl J Med 1999; 341:410,0,6,-31,-4,-35,-30,-25,-20,-15,-10,-5,0,5,10,Cholesterol LDL-C HDL-C Triglycerides,Percent change compared to placebo at 1 year,Secondary Prevention in 2531 men with low HDL-C & LDL-C showed a 22% re
5、duction in combined fatal and non-fatal MI,HDL - Cholesterol as Risk Factor for CHD,LRC - CPPT (Placebo),MRFIT (usual care),Incidence rate of CHD,Incidence rate of CHD,12 10 8 6 4 2 0,100 130 160 190,GORDON DJ et al. Circulation 1989; 79: 8 - 15.,HDL - C mg / dl 65 55 45 35,LDL - Cholesterol mg / dl
6、,LDL - Cholesterol mg / dl,12 10 8 6 4 2 0,100 130 160 190,0,0.5,1,1.5,2,2.5,3,Framingham Heart Study,CAD risk as a function of LDL-C and HDL-C in men (50 to 70 y),CASTELLI WP. Am J Cardiol 1998; 82:60-65,220 160 100,85,65,45,25,HDL-Cholesterol (mg/dl),LDL Cholesterol (mg/dL),0,2,4,6,8,10,12,14,16,L
7、DL=5,LDL5,HDL=1.08,HDL1.08,LDL/HDL=5,LDL/HDL5,Incidence of cardiac events,(per 1000 person-years),Gemfibrozil,Placebo,LDL-C Tertiles (mmol/L),HDL-C Tertiles (mmol/L),LDL-C/HDL-C Tertiles,Incidence for cardiac events vs lipid parameter,Helsinki Heart Study,AFCAPS/TEXCAPS,Apo B/A1 Tertiles,LDL-C/HDL-C
8、 Tertiles,1.6,1.4,1.2,1,0.8,0.6,0.4,0.2,0,1.6,1.4,1.2,1,0.8,0.6,0.4,0.2,0,Event Rate per 100 Patient-Years of Risk,Event Rate per 100 Patient-Years of Risk, 0.8889,0.8898- 1.0205,1.0252, 3.7742,3.7744-4.4096,4.4101,LDL/HDL Ratio as Therapeutic Success,Placebo,Statin,24,116,31,245,0,50,100,150,200,25
9、0,300,= 5, 5,LDL / HDL - Ratio,Triglycerides 200 mg/dl,Triglycerides = 200 mg/dl,CAD cases per 1,000 subjects in 6 years,Incidence of CAD vs LDL/HDL ratio by TG level (n = 4559),PROCAM Heart Study,0,50,100,150,200,250,300,3,4,5,5,6,7,LDL/HDL ratio,CHD Incidence/1000 in 6 years,CHD risk according to
10、LDL/HDL ratio at baseline,5,High CHD risk,Medium CHD risk,Low CHD risk,3-5,3,PROCAM Heart Study,Mean values for developing atherosclerotic CHD within 6 years,Variable CHD Development No CHD Development (n = 186) (n = 4221) TC (mg/dl) 251.8 222.9 HDL-C (mg/dl) 39.5 45.2 LDL-C (mg/dl) 176.2 147.1 LDL/
11、HDL ratio 4.72 3.4 TG (mg/dl) 163.0 134.5,PROCAM Heart Study,Predictive value of risk factors for developing atherosclerotic CHD within 6 years,Variable Risk Ratio Predictive Power % TG 200 mg/dl 2.3 7.5 TC 250 (mg/dl) 2.8 8.3 LDL-C 195 (mg/dl) 3.7 12.0 LDL-C 155 (mg/dl) 3.3 7.1 HDL-C 35 (mg/dl) 3.9
12、 11.0 LDL/HDL ratio 5 6.4 16.5,PROCAM Heart Study,HDL as CHD risk factor showed 186 events, in men aged 40 - 60 years (n = 4407),CHD Incidence per 1, 000 in 6 years,0,20,40,60,80,100,120,140,160, 35 35 - 55 55,HDL-C (mg/dL),110,30,21,PROCAM Heart Study,LDL as CHD risk factor showed 177 events in men
13、 aged 40 - 60 years, ( n = 4263),CHD Incidence per 1, 000 in 6 years,0,20,40,60,80,100,120,140, 135 135 - 154 155 - 195 195,LDL-C (mg/dL),54,30,16,31,120,PROCAM Heart Study,Expert Opinions,Part IV,The Lipid Triad - Expert Comments,AHA, November 1999 “Evaluating the risk on the bases of LDL alone, is
14、 naive” Valentin Fuster, Mount Sinai Medical Center, New York “The LDL/HDL ratio is a much stronger predictor for the CHD risk than LDL alone” Paul Ridker, Brigham Institute for Womens Hospital, Boston,ACCP, March 2000 “Low HDL is a better indicator of CHD than high LDL as seen in epidemiological st
15、udies such as the Framingham Study and recently the VA-HIT Study.” Sander Robins, University Medical Center, Boston “Landmark statin trials have shown consistent benefits on CHD reduction after raising HDL by 5 - 10% irrespective of LDL levels” Christie Ballantyne, Baylor College of Medicine, Houston,The Lipid Triad - Expert Comments,Helsinki Heart Study “The L
