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題 名 | 高脂血症處置之新進展:實證醫學的啟示=The Recent Advances on the Management of Hyperlipidemia: Implications from Evidence-Based Treatment |
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作 者 | 陳明豐; | 書刊名 | 內科學誌 |
卷 期 | 9:4 1998.12[民87.12] |
頁 次 | 頁153-161 |
分類號 | 415.38 |
關鍵詞 | 高脂血症; 實證醫學; Hyperlipidemia; Evidence-based medicine; |
語 文 | 中文(Chinese) |
中文摘要 | 臨床觀察,動物實驗以及流行病學的研究皆已確定血液膽固醇濃度愈高,心臟血 管疾病的致病率與死亡率也就愈高。當高三酸甘油酯血症與低的高密度酯蛋白膽固醇血症同 時出現時,心臟血管疾病之危險性才明顯增加。且高三酸甘油酯血症為高血壓、高血糖和低 的血清高密度脂蛋白引發冠狀動脈硬化之互動核心。 以脂蛋白為基礎的 Fredrickson 高脂 血症分類可以明確的表示其Ⅱ a、Ⅱ b 和Ⅳ型皆伴隨動脈硬化生成性, 並和飲食大有關係 。高脂血症之處置依 National Cholesterol Education Program 治療指引,首要建立血中 脂質濃度為處置目標,對不同類型和不同嚴重程度的脂蛋白異常分別評估病人,進行臨床檢 測, 並以脂質教育 (設定血中濃度、運動及飲食治療 ) 或藥物治療或其他更積極之治療法 處置病人,追蹤成效,故其執行為按步就班。無論飲食或藥物治療,其目標對無冠狀動脈疾 病 (coronary artery disease, CAD) 患者, 若非脂質冠狀動脈危險因素< 2 個,則總膽 固醇和低密度脂蛋白膽固醇 (LDL-C) 目標分別為< 240 mg/dL 和< 160 mg/dL;若非脂質 冠狀動脈危險因素≧ 2 個, 則此兩種血脂濃度降低目標分別為< 200 mg/dL 和< 130 mg/dL。 糖尿病患者之血脂治療目標和 CAD 患者一樣 (總膽固醇< 160 mg/dL, LDL-C < 100 mg/dL)。高膽固醇血症病人,已在各個長達數年的非藥物或各種藥物治療的臨床試驗評 估中,無論就初患預防或續發預防皆被証明降低血中膽固醇濃度可以減少冠狀動脈狹窄進行 , 甚至有回歸現象,降低 10 %血清膽固醇濃度, 在五年以上的臨床追蹤評估大約可降低 25 %的心臟血管疾病死亡率,對總死亡率和心肌梗塞發作也有顯著降低。Statin 藥物對高 脂血濃度降低效果有目共睹,但 " 脂質外效果 " 則尚無定見,考其原因和藥物為 prodrug 或 active form、代謝路徑、水溶性或脂溶性及次結構差異有關。 越多證據亦指出 statin 可以降低三酸甘油酯濃等,實則經由低密度脂蛋白濃度降低才達到降三酸甘油酯濃度減低心 臟血管疾病發作之效果。脂蛋白 LDL 和 HDL 對動脈硬化生成之作用必須更深入探討其機轉 , 而非強調其血液濃度並廓清原脂蛋白 -B(Apo-B) 的血液濃度及角色及降血脂藥物的機轉 探討是未來的研究方向。 |
英文摘要 | Mounting evidence from clinical observations, animal experiments and epidemiological studies have documented that hypercholesterolemia is positively correlated with the morbidity and mortality of atherosclerotic cardiovascular diseases. Hypertriglyceridemia is not strongly related to coronary artery disease (CAD) unless it is associated with low serum levels of high-density lipoprotein (HDL) cholesterol. The Fredrickson's classification clarifies the phenotypes of hyperlipoproteinemia and shows that diet is a very important factor responsible for hyperlipidemia and atherosclerosis. According to the guidelines of the National Cholesterol Education program, the management of hyperlipidemia is a stepped-care procedure including the set-up of the goal of the treatment based on the presence of CAD or not. In patients without CAD and the non-lipid coronary risk facotors is below 2, the goal of treatment is to maintain serum total and low-density lipoprotein (LDL) cholesterol levels below 240 and 160 mg/dL, respectively, however, for those patients without CAD but with two or more non-lipid coronary risk factors, the goal is 200 and 130 mg/dL, respectively. In patients with CAD or diabetes, it is necessary to treat total and LDL cholesterol levels below 160 and 100 mg/dL, respectively. In many non-pharmacological or drug trials, primary or secondary preventions have been shown to attenuate the progression and even to regress the severity of atherosclerosis, and decrease the morbidity and mortality of coronary events. It is estimated that 10% reduction of serum cholesterol levels for 5 years will reduce the coronary risk by 25%. The lipid-lowering effect of 3-hy- droxyl-3-methylglutaryl co-enzyme A reductase inhibitors (statins) has been well documented. However, the prodrug or active form, metabolic pathways, water or lipid solubility and substructure variations may attributed to the difference of extra-lipid effect of statins. Increasing data implicated that by lowering triglyceride-contained LDL levles, statins may act as a triglyceride-lowering agent. The role of statins to reduce cardiac events in patients with normal or upper normal cholesterol levels remains controversy. In stead of plasma levels, it is more important to clarify the detail mechanisms of apolipoprotein-B, LDL and HDL on the development of atherosclerosis. |
本系統中英文摘要資訊取自各篇刊載內容。