缺血性卒中后低密度脂蛋白胆固醇两种降脂目标的比较
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A Comparison of Two LDL Cholesterol Targets after Ischemic Stroke
背景与目的
短暂性脑缺血发作(TIA)和动脉粥样硬化缺血性卒中后，推荐使用他汀类药物强化降脂治疗。然而，减少卒中后心血管事件发生率的低密度脂蛋白(LDL)胆固醇的降脂水平尚未得到深入研究。
方 法
本项在法国和韩国进行的平行对照试验中，我们选取了3个月内发生缺血性卒中或15天内发生TIA的患者，并随机分为LDL胆固醇目标水平低于70mg /dL(1.8 mmol/L)(低目标组)或LDL胆固醇目标范围为90mg /dL~110mg /dL(2.3~2.8 mmol/L)(高目标组)。所有患者均有脑血管或冠状动脉粥样硬化的迹象，并服用他汀类药物、依替米贝或两种药物配伍治疗。主要心血管事件的复合主要结局包括缺血性卒中、心肌梗死、导致紧急冠状动脉或颈动脉血管重建的新发症状，或心血管原因引起的死亡。
结 果
本研究共纳入2860例患者，随访时间中位数为3.5年；每个LDL胆固醇目标组均分配了1430名患者。LDL胆固醇基线时的平均水平为135mg/dL(3.5 mmol/L)，低目标组的LDL胆固醇平均水平为65mg/dL（1.7mmol/L），高目标组为96mg/dL（2.5mmol/L）。预期的385例患者中有277例发生主要心血管事件后，该试验因行政原因被停止。低目标组有121(8.5%)例患者出现复合主要结局，高目标组出现156(10.9%)例(校正风险比 0.78；95% CI 0.61 ~ 0.98；P = 0.04)。两组间颅内出血和新发糖尿病的发生率无显著差异。
结 论
发生动脉粥样硬化缺血性卒中或TIA后，降脂目标为LDL胆固醇低于70 mg/dL的患者发生心血管意外的风险，比LDL胆固醇目标范围为90mg/dL~110mg/dL的患者更低。
原始文献摘要
Amarenco P, Kim JS, Labreuche J, et al. A Comparison of Two LDL Cholesterol Targets after Ischemic Stroke.[J].N Engl J Med. 2020,382(1):9.
BACKGROUND
The use of intensive lipid-lowering therapy by means of statin medications is recommended after transient ischemic attack (TIA) and ischemic stroke of atherosclerotic origin. The target level for low-density lipoprotein (LDL) cholesterol to reduce cardiovascular events after stroke has not been well studied.
METHODS
In this parallel-group trial conducted in France and South Korea, we randomly assigned patients with ischemic stroke in the previous 3 months or a TIA within the previous 15 days to a target LDL cholesterol level of less than 70 mg per deciliter (1.8 mmol per liter) (lower-target group) or to a target range of 90 mg to 110 mg per deciliter (2.3 to 2.8 mmol per liter) (higher-target group). All the patients had evidence of cerebrovascular or coronary-artery atherosclerosis and received a statin, ezetimibe, or both. The composite primary end point of major cardiovascular events included ischemic stroke, myocardial infarction, new symptoms leading to urgent coronary or carotid revascularization, or death from cardiovascular causes.
RESULTS
A total of 2860 patients were enrolled and followed for a median of 3.5 years; 1430 were assigned to each LDL cholesterol target group. The mean LDL cholesterol level at baseline was 135 mg per deciliter (3.5 mmol per liter), and the mean achieved LDL cholesterol level was 65 mg per deciliter (1.7 mmol per liter) in the lower-target group and 96 mg per deciliter (2.5 mmol per liter) in the higher-target group. The trial was stopped for administrative reasons after 277 of an anticipated 385 end-point events had occurred. The composite primary end point occurred in 121 patients (8.5%) in the lower-target group and in 156 (10.9%) in the higher-target group (adjusted hazard ratio, 0.78; 95% confidence interval, 0.61 to 0.98; P=0.04). The incidence of intracranial hemorrhage and newly diagnosed diabetes did not differ significantly between the two groups.
CONCLUSIONS
After an ischemic stroke or TIA with evidence of atherosclerosis, patients who had a target LDL cholesterol level of less than 70 mg per deciliter had a lower risk of subsequent cardiovascular events than those who had a target range of 90 mg to 110 mg per deciliter.
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贵州医科大学高鸿教授课题组
翻译：冯玉蓉 编辑：冯玉蓉 审校：王贵龙