Clinical Practice 2022 Taiwan lipid guidelines for primary prevention 04

Risk calculator
風險計算
對於初級預防，人口研究衍生的 ASCVD 風險估計計算器，例如 Framingham 風險評分，通常用於決定受試者是否應該接受降脂治療。近年來，美國心髒病學會 (ACC) 和美國心臟協會 (AHA) 開發了合併隊列方程。 15,16 歐洲心髒病學會 (ESC) 和歐洲動脈粥樣硬化學會 (EAS) 使用 SCORE（系統性冠狀動脈風險評估）用於 ASCVD 風險評估。17,18 英國國家健康與護理卓越研究所 (NICE) 指南使用 QRISK2 作為 ASCVD 風險評估工具。19 儘管存在多種特定於人群的風險評估工具，但目前可用的模型均未派生來自或在東亞人中前瞻性驗證。用於估計 10 年 ASCVD 事件風險的 AHA/ACC 合併隊列方程適用於 40 至 79 歲的黑人和非西班牙裔白人男性和女性。15 該風險預測因子可能高估了中國人群的 ASCVD 風險。 20 Framingham 風險評分也高估了華人的 ASCVD 風險。 21 在台灣，1990 年代的金山社區心血管隊列研究開發了一個基於點的預測模型來預測 CAD 的 10 年風險。 22 然而，沒有指出定義高風險的明確分界點。一些檢查，如踝肱指數、脈搏波速度、頸動脈超聲和冠狀動脈鈣化評分，已被用於 ASCVD 風險評估。這些檢查的可及性是當地診所的一個主要問題。冠狀動脈鈣化評分檢查的成本和輻射暴露問題也是重要的考慮因素。基本上，該指南不鼓勵在無症狀受試者中常規篩查亞臨床動脈粥樣硬化的存在。目前階段，使用風險因素的數量是台灣風險分層的一種更方便的方法。風險類別 高風險（DM、CKD 和 LDL-C ‡ 190 mg/dL） 本初級預防指南決定保留常規目標方法，並根據 CV 風險因素的存在定制 LDL-C 治療目標。由於 ASCVD 是導致 DM 和 CKD 人群顯著死亡率的一個主要問題，因此這兩組患者被認為處於高風險中。2017 年台灣高危患者血脂指南描述了 DM 的診斷和糖尿病血脂異常的管理策略。10 對於 CKD，白蛋白尿是用於檢測和定義 CKD 的重要生物標誌物。白蛋白尿是指尿中白蛋白排泄增加。未計時尿樣中的尿白蛋白與肌酐比值 (UACR) 已取代 24 小時尿白蛋白排泄量，成為測量白蛋白尿的首選方法。23e26 白蛋白尿定義為 UACR 30 mg/g，可進一步分為微量白蛋白尿(UACR 30e300 mg/g) 和大量白蛋白尿 (UACR > 300 mg/g)。國家腎臟基金會腎臟疾病結果質量倡議 (KDOQI) 指南將 CKD 定義為腎臟損傷 (UACR 30 mg/g) 或腎小球濾過率 (GFR) < 60 mL/min/1.73 m2 至少三個月。27，28 GFR 通常根據腎臟疾病飲食改良 (MDRD)29 或慢性腎髒病流行病學協作 (CKD-EPI) 方程式從血清肌酐水平估算。 30 建議對 DM 和非糖尿病患者立即進行降脂治療-透析 CKD。定義為 LDLC 190 mg/dL 的嚴重高膽固醇血症具有 ASCVD 和早發 CV 事件的高風險。與一般人群相比，這些人患 CAD 的風險高 5 到 6 倍，男性患 CAD 的時間早 10-20 年，女性早 20-30 年。 31 早期開始降脂治療可以顯著降低這些受試者的發病率和死亡率。 32 LDL-C 190 mg/dL 顯著增加了 FH 存在的可能性。大約 7% 的 LDLC 190 mg/dL 的受試者可能符合 FH 的診斷標準。33 應考慮對這組受試者進行基因檢測以診斷 FH。先前的研究表明，與 LDL-C <130 mg/dL 且未檢測到 FH 基因突變的參考組相比，LDL-C 190 mg/dL 且未檢測到 FH 突變的受試者患 CAD 的風險高 6 倍，而那些LDL-C 190 mg/dL 和 FH 突變的風險增加了 22 倍。 34 因為 LDL-C 190 mg/dL 是一個非常獨特的高風險組，具有明顯的長期臨床結果，它被歸類為作為高風險。就像 DM 和 CKD 一樣，建議立即進行降脂治療並強化 LDL-C 控制，因為這些患者的 CV 風險非常高。與 LDL-C <130 mg/dL 且未檢測到 FH 基因突變的參考組相比，LDL-C 190 mg/dL 且未檢測到 FH 突變的受試者患 CAD 的風險高 6 倍，而那些同時具有 LDL-C 和190 mg/dL 和 FH 突變表明風險增加 22 倍。34 由於 LDL-C 190 mg/dL 是一個非常獨特的高風險組，具有明顯的長期臨床結果，因此它被歸類為高風險。就像 DM 和 CKD 一樣，建議立即進行降脂治療並強化 LDL-C 控制，因為這些患者的 CV 風險非常高。與 LDL-C <130 mg/dL 且未檢測到 FH 基因突變的參考組相比，LDL-C 190 mg/dL 且未檢測到 FH 突變的受試者患 CAD 的風險高 6 倍，而那些同時具有 LDL-C 和190 mg/dL 和 FH 突變表明風險增加 22 倍。34 由於 LDL-C 190 mg/dL 是一個非常獨特的高風險組，具有明顯的長期臨床結果，因此它被歸類為高風險。就像 DM 和 CKD 一樣，建議立即進行降脂治療並強化 LDL-C 控制，因為這些患者的 CV 風險非常高。34 因為 LDL-C 190 mg/dL 是一個非常獨特的高風險組，具有明顯的長期臨床結果，所以它被歸類為高風險。就像 DM 和 CKD 一樣，建議立即進行降脂治療並強化 LDL-C 控制，因為這些患者的 CV 風險非常高。34 因為 LDL-C 190 mg/dL 是一個非常獨特的高風險組，具有明顯的長期臨床結果，所以它被歸類為高風險。就像 DM 和 CKD 一樣，建議立即進行降脂治療並強化 LDL-C 控制，因為這些患者的 CV 風險非常高。

For primary prevention, population study-derived ASCVD risk estimate calculators, such as the Framingham risk score, are commonly used to decide whether a subject should receive lipid-lowering therapy or not. In recent years, the American College of Cardiology (ACC) and the American Heart Association (AHA) developed the pooled cohort equation.15,16 The European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS) used SCORE (Systematic COronary Risk Evaluation) for ASCVD risk assessment.17,18 The UK National Institute for Health and Care Excellence (NICE) guidelines used the QRISK2 as the ASCVD risk assessment tool.19 Although several populationspecific risk assessment tools exist, none of the currently available models are derived from or prospectively validated in East Asians. The AHA/ACC pooled cohort equation for estimating the 10-year risk of ASCVD event is applicable to black and non-Hispanic white men and women 40 through 79 years of age.15 This risk predictor may overestimate the ASCVD risk in the Chinese population.20 The Framingham risk score also overestimated the ASCVD risk for ethnic Chinese.21 In Taiwan, a point-based prediction model to predict the 10-year risk of CAD was developed from the Chin-Shan Community Cardiovascular Cohort study in 1990s.22 However, the definite cut-off point to define high risk was not indicated. Some examinations, such as ankle-brachial index, pulse wave velocity, carotid ultrasound, and coronary calcium score, have been used in ASCVD risk assessment. The accessibility of these examinations is a major problem in local clinics. Concerns of cost and radiation exposure for examination of coronary calcium score are also important considerations. Basically, this guideline does not encourage to routinely screen the presence of subclinical atherosclerosis in asymptomatic subjects. At current stage, using the numbers of risk factors is a more convenient way for risk stratification in Taiwan. Risk category High risk (DM, CKD and LDL-C ‡ 190 mg/dL) This primary prevention guideline decides to keep a conventional target approach and the LDL-C treatment targets are tailored according to the presence of CV risk factors. Since ASCVD is a major problem contributing to significant mortality in populations with DM and CKD, these 2 groups of patients are considered at high risk. The diagnosis of DM and management strategy of diabetic dyslipidemia was described in the 2017 Taiwan Lipid Guidelines for High Risk Patients.10 For CKD, albuminuria is an important biomarker which is used to detect and define CKD. Albuminuria refers to increased urinary excretion of albumin. The urine albumin-to-creatinine ratio (UACR) in an untimed urine specimen has replaced 24-h urine albumin excretion as the preferred method for measuring albuminuria.23e26 Albuminuria is defined as a UACR
30 mg/g and can be further categorized into microalbuminuria (UACR 30e300 mg/g) and macroalbuminuria (UACR > 300 mg/g). The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines defined CKD as kidney damage (UACR
30 mg/g) or a glomerular filtration rate (GFR) < 60 mL/min/1.73 m2 for at least three months.27,28 The GFR is usually estimated from the serum creatinine level according to equations of the Modification of Diet in Renal Disease (MDRD)29 or the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI).30 Immediate lipid lowering therapy is recommended for DM and non-dialysis CKD. Severe hypercholesterolemia, defined as having an LDLC
190 mg/dL, carries a high risk of ASCVD and premature CV events. These individuals have a 5 to 6-fold higher risk of CAD and develop CAD 10e20 years earlier in men and 20e30 years earlier in women than general population.31 Early initiation of lipid-lowering therapy can significantly reduce morbidity and mortality in these subjects.32 LDL-C
190 mg/dL significantly increases the likelihood for the presence of FH. Approximately 7% of the subjects with LDLC
190 mg/dL may fulfill the diagnostic criteria of FH.33 Genetic testing should be considered for this group of subjects for diagnosis of FH. Previous study demonstrated that, compared with a reference group with LDL-C <130 mg/dL without detected FH genetic mutation, subjects with LDL-C
190 mg/dL without detected FH mutation had a 6-fold higher risk for CAD, whereas those with both LDL-C
190 mg/dL and an FH mutation demonstrated a 22-fold increased risk.34 Because LDL-C
190 mg/dL is a very unique and high risk group with a distinct long-term clinical outcome, it is classified as high risk. Just like DM and CKD, immediate lipid lowering therapy with intensive LDL-C control is recommended because the CV risk is so high in these patients.