Clinical Practice 2022 Taiwan lipid guidelines for primary prevention 02

台灣2022年血脂治療指引部分更新

一級預防的定義 由於這是一項一級預防指南，因此應首先描述具有臨床意義的 ASCVD 的定義。已經證明動脈粥樣硬化早在 2 歲時就起源於兒童期。一系列病理學研究，從在朝鮮戰爭和越南戰爭中陣亡的士兵的屍檢到最近的青年動脈粥樣硬化的病理生物學決定因素 12 和 Bogalusa 心臟研究 13，表明冠狀動脈脂肪條紋在生命早期形成，晚期纖維斑塊存在於青少年的比例。在過去的幾十年裡，令人信服的證據表明，吸煙、血脂異常、高血壓、胰島素抵抗、肥胖和 DM 等 CV 危險因素在整個生命週期中加速了動脈粥樣硬化過程。14 “一級預防”的主要目的是指通過消除或改變危險因素來預防有臨床意義的 ASCVD。具有臨床意義的 ASCVD 包括： (1) 冠心病，如負荷試驗陽性心絞痛和/或影像學檢查冠狀動脈主動脈直徑狹窄>50%；(2)ACS，如心肌梗死、不穩定型心絞痛；(3)腦血管病，如短暫性腦缺血發作、缺血性腦卒中、影像學檢查發現頸動脈狹窄>50%；(4)影像學檢查顯示大肢動脈直徑狹窄>50%的PAD；(5) 主動脈粥樣硬化疾病，如腹主動脈瘤的影像學檢查。有臨床意義的 ASCVD 血脂異常的治療應參考 2017 年台灣高危患者血脂指南及其重點更新中的建議。該一級預防指南闡述了在沒有臨床意義的 ASCVD 的受試者中控制血脂的一般原則。危險分層是確定一級預防降脂策略的第一步。

Definition of primary prevention Since this is a primary prevention guideline, the definitions of clinically significant ASCVD should be described first. It has been demonstrated that atherosclerosis originates in childhood as early as 2 years of age. A series of pathology studies, from autopsies of soldiers killed in the Korean and Vietnam Wars to the more recent Pathobiological Determinants of Atherosclerosis in Youth12 and Bogalusa Heart studies,13 demonstrated that coronary fatty streaks develop early in life and advanced fibrous plaques are present in a proportion of adolescents. During the past decades, convincing evidence has emerged that CV risk factors, such as cigarette smoking, dyslipidemia, hypertension, insulin resistance, obesity, and DM, accelerate the atherosclerotic process throughout the life span.14 The major purpose of “primary prevention” refers to prevention of clinically significant ASCVD by removing or modifying risk factors. The clinically significant ASCVD include: (1) CAD, such as angina with positive stress test and/or major coronary artery diameter stenosis >50% by imaging studies; (2) ACS, such as myocardial infarction and unstable angina; (3) cerebrovascular disease, such as transient ischemic attack, ischemic stroke, and carotid artery stenosis >50% by imaging studies; (4) PAD with major extremity artery diameter stenosis >50% by imaging studies; and (5) aortic atherosclerotic disease, such as abdominal aortic aneurysm by imaging studies. Treatment of dyslipidemia for clinically significant ASCVD should be referred to the recommendations in the 2017 Taiwan Lipid Guidelines for High Risk Patients and its focused update. This primary prevention guideline addresses the general principles of lipid control in subjects without clinically significant ASCVD. Risk stratification is the first step to determine the lipid lowering strategy in primary prevention.