Clinical Practice 2022 Taiwan lipid guidelines for primary prevention 01

台灣2022年血脂治療指引部分更新
早期開始他汀類藥物治療以降低 LDL-C 可以獲得與未經治療的低 LDL-C 水平患者相似的 CV 風險。8
很明顯，在生命早期維持足夠的 LDL-C 水平是預防 ASCVD 的有效干預措施。然而，台灣LDL-C的控制率令人失望。即使在患有 ASCVD 的患者中，也只有 54% 的患者可以達到 <100 mg/dL 的 LDL-C 水平。9

台灣血脂與動脈粥樣硬化學會與台灣其他七個主要學會聯合發布了台灣血脂高危指南風險患者 2017.10 推薦高危患者的最佳血脂目標和治療策略，
包括冠心病（CAD）、急性冠脈綜合徵（ACS）、缺血性卒中、外周動脈疾病（PAD）、糖尿病（DM） , 慢性腎病 (CKD) 和家族性高膽固醇血症 (FH)。

2017年台灣高危患者血脂指南在台灣獲得好評，成為高危患者血脂異常治療的標準指南。2017年指南未提及對不具有上述高危特徵的受試者進行血脂異常管理。

在 2005 年至 2008 年台灣進行的營養與健康調查中，高膽固醇血症定義為膽固醇水平 240 毫克/分升，男性佔 12.5%，女性佔 10%。 11 台灣血脂與動脈粥樣硬化學會決定向前推進一級預防並針對沒有臨床顯著 ASCVD 但可能攜帶其他各种血管危險因素的受試者制定了新的血脂指南。

2020年11月至2021年3月，台灣脂質與動脈粥樣硬化學會召開顧問委員會會議，來自台灣家庭醫學會、台灣心髒病學會、台灣中風學會、台灣糖尿病協會、台灣糖尿病教育者協會的專家和意見領袖、台灣腎病學會及台灣血脂教育者協會出席顧問委員會會議並提出重要建議。

科學證據是該指南的主要考慮因素。然而，我們認識到台灣可能沒有足夠的數據來支持血脂異常管理各個方面的一級預防建議。許多建議是專家意見經過討論後達成的共識。

與2017年台灣高危患者血脂指南類似，本指南使用推薦等級 (COR) 和證據等級 (LOE) 來描述推薦強度及其相關科學證據。10 COR 包括 3 個等級，包括 I 級（推薦有用、指示和必要） 、IIa 類（建議可能有用且有指示性，但其證據強度低於 I 類）、IIb 類（可以考慮這些建議，但其效果不太確定）和 III 類（建議指的是治療是有害的，禁忌的，不應該這樣做）。LOE 也有 3 個級別，包括 LOE A（建議得到多項隨機臨床試驗的支持）、LOE B（建議僅來自有限的隨機試驗或觀察性研究）、
Introduction Cardiovascular (CV) disease, including atherosclerotic cardiovascular disease (ASCVD), is one of the major leading causes of death in Taiwan.1 Multiple evidences from laboratory, epidemiological, and genetic studies indicate that increased circulating low-density lipoprotein cholesterol (LDL-C) causes accelerated deposition of cholesterol in the arterial wall leading to vascular inflammation and atherosclerosis.2,3 The causal link of LDL-C and ASCVD was further proved in many clinical trials showing that intensive reduction of LDL-C is an effective therapy to attenuate the progression of coronary atherosclerosis and improve CV outcomes.4e7 Recent study demonstrated that, in individuals without established coronary atherosclerosis, early initiation of statin therapy to decrease LDL-C could obtain a similar CV risk as those with untreated low LDL-C levels.8 It is clear that maintaining an adequate LDL-C level earlier in life is an effective intervention for prevention of ASCVD. However, the control rate of LDL-C is disappointing in Taiwan. Even in patients with ASCVD, only 54% of them could achieve an LDL-C level <100 mg/dL.9 The Taiwan Society of Lipids and Atherosclerosis, in association with seven other major societies in Taiwan, published the Taiwan Lipid Guidelines for High Risk Patients in 2017.10 The optimal lipid target and treatment strategy were recommended for high risk patients, including those with coronary artery disease (CAD), acute coronary syndrome (ACS), ischemic stroke, peripheral artery disease (PAD), diabetes mellitus (DM), chronic kidney disease (CKD), and familial hypercholesterolemia (FH). The 2017 Taiwan Lipid Guidelines for High Risk Patients received critical acclaim in Taiwan and became the standard guidance for dyslipidemia treatment in high risk patients. The management of dyslipidemia for subjects without the above-mentioned high risk features was not mentioned in the 2017 guidelines. In the Nutrition and Health Surveys in Taiwan performed from 2005 to 2008, hypercholesterolemia defined as a cholesterol level
240 mg/dL was found in 12.5% in men and 10% in women.11 The Taiwan Society of Lipids and Atherosclerosis decided to move forward to primary prevention and developed a new lipid guideline targeting the subjects without clinically significant ASCVD, but may carry other various vascular risk factors. Advisory board meetings were held by the Taiwan Society of Lipids and Atherosclerosis from November 2020 to March 2021. Experts and opinion leaders from the Taiwan Association of Family Medicine, Taiwan Society of Cardiology, Taiwan Stroke Society, Taiwan Diabetes Association, Taiwan Association of Diabetes Educators, Taiwan Society of Nephrology and Taiwan Association of Lipid Educators attended the advisory board meetings and gave important suggestions. Scientific evidence is the major consideration of the guideline. However, we recognized that there may be insufficient data in Taiwan to support the recommendations in every aspect of dyslipidemia management for primary prevention. Many recommendations were consensus from the expert opinions after discussion. Similar to the 2017 Taiwan Lipid Guidelines for High Risk Patients, this guideline uses class of recommendation (COR) and level of evidence (LOE) to describe the intensities of the recommendations and their related scientific evidence.10 The COR includes 3 levels, including class I (the recommendations are useful, indicated, and necessary), class IIa (the recommendations maybe useful and indicated, but their intensity of evidence are less than class I), class IIb (the recommendations could be considered but their effects are less well established) and class III (the recommendations refer to the treatment that is harmful, contraindicated, and should not be done). The LOE also has 3 levels, including LOE A (the recommendations are supported by multiple randomized clinical trials), LOE B (the recommendations are from limited randomized trials or observational studies only), LOE C (the recommendations are from experts’ consensus).