我們要不要降血脂，前面兩篇文章讓讀者有疑惑。您看Christopher P. Cannon醫(yī)生（哈佛大學(xué)醫(yī)學(xué)院附屬布列根和婦女醫(yī)院）（也是JAMA 美國(guó)醫(yī)學(xué)會(huì)雜志的編委）是最為激進(jìn)的降血脂派，他的觀點(diǎn)是'lower isbetter（越低越好）’。但是筆者在這里給大家傳遞一個(gè)觀點(diǎn)，現(xiàn)代醫(yī)學(xué)之父威廉奧斯勒這樣描述醫(yī)學(xué)，'一門(mén)不確定科學(xué)和可能性的藝術(shù)?！?所以我們還是要建議有心血管疾病風(fēng)險(xiǎn)的患者控制膽固醇水平，但是自然降血脂減少對(duì)藥物的依賴是最好的方法。

這里給出六條自然降血脂的小提示，供大家參考：

• 多吃含有單一不飽和脂肪酸的食物。很多控脂飲食方案雖然會(huì)降低體重，減少血液中所謂有害的膽固醇（LDL），但是也會(huì)減少血液中所謂有益的膽固醇（HDL）。但是富含單一不飽和脂肪酸的食物就只減少LDL，不減少HDL。這類(lèi)食物有，橄欖和橄欖油、菜籽油、堅(jiān)果類(lèi)食物（杏仁、花生、山核桃、榛子、腰果等）、牛油果

• 多食用富含多不飽和脂肪酸的食物，特別是富含Omega-3s的食物。例如，三文魚(yú)、馬鮫魚(yú)、鯡魚(yú)、還有深海魚(yú)類(lèi)比如金槍魚(yú)，以及植物的種子（不包括花生）等

• 多吃可溶性纖維。這類(lèi)食物包括豆類(lèi)食物、各種水果、燕麥和全麥等等

• 在物理治療師和健康教練的指導(dǎo)下科學(xué)鍛煉與減肥。

• 不要吸煙，控制飲酒等等。

好了，市民朋友們就看到這里了，請(qǐng)您關(guān)注作者，了解更多醫(yī)養(yǎng)知識(shí)。

專業(yè)同行繼續(xù)往下看。

       首先建議大家看一下Peter Lin醫(yī)生對(duì)于最新的2018膽固醇指南的總結(jié)，Peter是加拿大心臟研究中心，全科醫(yī)學(xué)項(xiàng)目總監(jiān)。他這篇對(duì)指南的總結(jié)強(qiáng)調(diào)了對(duì)患者心血管風(fēng)險(xiǎn)評(píng)估的重要性，因?yàn)橹挥性谡_評(píng)估的基礎(chǔ)上才能決定用藥的程度與指導(dǎo)患者減少對(duì)藥物依賴的方案。

Cholesterol Guidelines 2018: Quick Summary

This article provides the highlights of thefirst lipid guideline update since 2013. That 2013 guideline created hugedebates because there was a deemphasis on LDL-C targets and statin was the mainrecommended therapy. This was because, up to 2013, the studies that showed CVbenefits were mainly statin trials. Also, these studies were not target-driven;they just gave the dose of statin and wherever the LDL-C ended was where itended. So, the 2013 guidelines followed what was done in the trials andrecommended statins of the same intensity that were used in the trials asopposed to specific LDL-C targets.

Now in the last few years, the PCSK9inhibitor trials have come out and, in the very high risk ASCVD population, theaddition of a PCSK9 inhibitor did reduce CV events beyond statins alone.Therefore, we can add them to statins. Also, ezetimibe showed some modestbenefits on top of simvastatin as well. Hence, this new guideline deals withwhen we should be thinking of adding on these medications while alwaysremembering that the cost could be significant.

The guidelines start off by looking at therisks and the benefits. So first, we assess the risk of the patient then decidehow much treatment is needed. As before, there are patients at such high riskthat you don’t need a risk calculation. They all need treatment withhigh-intensity statin. The goal is at least 50% reduction in LDL-C.

The “very high risk ASCVD” patients whoseLDL-C levels are still more than 70 mg/dL are like the patients in the PCSK9inhibitor trials. If, despite high-dose statins, their LDL-C is still above 70mg/dL, we can add ezetimibe and thereafter we can consider a PCSK9 inhibitor.The ezetimibe was not a requirement in the PCSK9 inhibitor trials; but, foreconomic purposes, it should be considered before a PCSK9 inhibitor.

The definition of a “very high risk ASCVD”patient is someone with multiple ASCVD events or with just one ASCVD event butadditional risk factors (age >65 years, diabetes, hypertension, chronickidney disease, heart failure, smoking, prior CABG/PCI, or persistent LDL-C>100 mg/dL). In other words, a 65-year-old with an MI or a diabetes patientwith an MI would be considered very high risk. So, these are not patients whoonly specialists see. They are very much in our primary care offices.

The next category in the guidelines are thepatients with LDL-C >190 mg/dL. This captures the familiarhypercholesterolemia patients and they, too, can be treated without doing arisk calculation. The target is at least 50% reduction in LDL-C, and the LDL-Cshould be <100 mg/dL.

Also, the risk is high enough in patientswith only diabetes that they do not need a risk calculation and they should betreated with statin therapy; however, the diabetes trials only usedmoderate-intensity statin dosing. Therefore, the recommendation is to usemoderate-intensity statins with at least a 30% LDL-C reduction. This seems tobe undertreatment of a high-risk population, but that is what happens when youhave to follow trials to a “T.” Sometimes we are trapped by “evidence-basedmedicine” because we can only recommend what has been proven.

Finally, for patients who do not haveASCVD, LDL-C >190 mg/dL, or diabetes, then we do need to use the CV riskcalculator. The new ranges for 10-year risks are as follows: 1) low risk,<5%; 2) borderline risk, 5 to 7.4%; 3) intermediate risk, 7.5% to 19.9%; and4) high risk, >20%. The two extremes are simple to remember. For high-riskpatients, treat them like ASCVD patients, which means high-intensity statintherapy and at least a 50% reduction in LDL-C. Low-risk patients don’t needtreatment. Intermediate risk is always the grey area. However, HOPE-3 was astudy that looked at the intermediate-risk patient, and rosuvastatin 10 mg didreduce CV events. Hence, most intermediate-risk patients should be treated.Now, for borderline risk patients, we need to look at other high-risk features,including family history of ASCVD, metabolic syndrome, and CKD. A calcium scoremay be useful, but usually reserved for those uncertain cases, which arehopefully few in number.

This guideline has nicely incorporated theevidence from the new trials and has given good guidance on when we should bethinking of statin therapy and when we should be thinking about the addition ofezetimibe or PCSK9 inhibitors. Hopefully this will help us get the righttherapy for the right patient—in a sense, this embodies the concept ofpersonalized medicine.

資料來(lái)源：Grundy SM, Stone NJ, Bailey AL, et al.2018 AHA/ ACC/ AACVPR/ AAPA/ ABC/ ACPM/ ADA/ AGS/ APhA/ ASPC/ NLA/ PCNAguideline on the management of blood cholesterol: a report of the AmericanCollege of Cardiology/American Heart Association Task Force on ClinicalPractice Guidelines. J Am Coll Cardiol. 2018 Nov 8. doi:10.1016/j.jacc.2018.11.003. [Epub ahead of print.]https://www./science/article/pii/S073510971839034X