2022-台灣高血脂初級預防指引-18-其他血脂數值控制目標 Non-HDL-C and apoB

2025-12-09 11:08AM

2022台灣血脂治療指引(英文版)下面中文使用google自動翻譯

其他脂質標靶和殘餘風險

非高密度脂蛋白膽固醇和載脂蛋白B

除了低密度脂蛋白膽固醇（LDL-C）外，其他幾種脂質或脂蛋白的水平也可用於預測動脈粥狀硬化性心血管疾病（ASCVD）的風險。非高密度脂蛋白膽固醇（非HDL-C）、載脂蛋白B（apoB）和三酸甘油酯（TG）近年來備受關注。非HDL-C的計算方法為總膽固醇（TC）減去高密度脂蛋白膽固醇（HDL-C）。高密度脂蛋白顆粒中的主要載脂蛋白成分是載脂蛋白A、C和E，但不含載脂蛋白B。因此，非HDL-C的計算反映了循環系統中所有含載脂蛋白B的脂蛋白的總和。富含膽固醇和三酸甘油酯的含載脂蛋白B的脂蛋白直徑小於70 nm，能夠輕易穿過血管內皮。滯留在動脈壁內的載脂蛋白B（apoB）脂蛋白會引發細胞反應，加速脂質/脂蛋白的進一步滯留和動脈粥狀硬化斑塊的進展。 ¹¹² 然而，一些研究發現非高密度脂蛋白膽固醇（non-HDL-C）和apoB水平之間存在差異，提示apoB可能是更準確的風險標記。 ^113,114 雖然在大多數人中，低密度脂蛋白膽固醇（LDL-C）、non-HDL-C和apoB之間存在良好的相關性，但在三酸甘油酯（TG）升高、糖尿病（DM）和肥胖人群中，LDL-C的測量值可能被低估，從而低估了動脈粥樣硬化性心血管疾病（ASCVD）的風險。 ^18,115 對於已接受他汀類藥物治療的台灣族群，non-HDL-C還可以提供殘餘風險評估。 ^116,117 由於在台灣的大多數醫院或診所，non-HDL-C的數據比apoB更容易獲得，因此建議將non-HDL-C水平作為LDL-C之後的次要目標。 ¹⁰非高密度脂蛋白膽固醇（non-HDL-C）比建議的低密度脂蛋白膽固醇（LDL-C）目標值高出30 mg/dL。例如，如果LDL-C目標值為100 mg/dL，則non-HDL-C的次要目標值為130 mg/dL。鑑於載脂蛋白B（apoB）在動脈粥狀硬化中的關鍵作用，如果實驗室具備檢測條件，也可以考慮直接測量循環apoB濃度來評估風險。在2019年歐洲血脂指引中，建議極高危險群、高危險群和中度危險群的apoB目標值分別為<65 mg/dL、<80 mg/dL和<100 mg/dL。 ¹⁸ 由於台灣大多數醫院或診所無法偵測apoB，且apoB在臨床實務中也很少使用，因此指引未建議特定的apoB目標值。

建議：非高密度脂蛋白膽固醇 (Non-HDL-C) 和載脂蛋白B (apoB) 可用於預測動脈粥狀硬化性心血管疾病 (ASCVD) 的風險，特別適用於高三酸甘油酯 (TG) 水平（>150 mg/dL）、糖尿病 (DM)、肥胖或代謝症候群患者。 （證據等級 IIa，證據等級 B）非高密度脂蛋白膽固醇作為次要目標，其目標值為比建議的低密度脂蛋白膽固醇 (LDL-C) 目標值高 30 mg/dL。 （證據等級 IIa，證據等級 B）

Other lipid target and residual risk

Non-HDL-C and apoB

In addition to LDL-C, the levels of several other lipids or lipoproteins also may be used to predict the risk of ASCVD. Non-high-density lipoprotein cholesterol (non-HDL-C), apolipoprotein-B (apoB) and TG have attracted attention recently. Non-HDL-C is calculated as TC minus HDL-C. The major components of apolipoproteins in HDL particles are apolipoprotein A, C, E and without apoB. Therefore, the calculation of non-HDL-C estimates the summation of all circulatory apoB-containing lipoproteins. Cholesterol-rich and triglyceride-rich apoB-containing lipoproteins have diameter less than 70 nm and can easily flux across the vascular endothelium. The trapped apoB-lipoproteins within the arterial wall trigger cellular responses that accelerate further lipid/lipoprotein retention and progression of atheromatous plaque.112 However, some studies found there was discordance between the levels of nonHDL-C and apoB suggesting apoB as a more accurate risk marker.113,114 Although there are well correlations between LDL-C, non-HDL-C, and apoB in most people, LDL-C measurement may be underestimated in those with elevated TG, DM, and obesity, thus underestimating the risk of ASCVD.18,115 Non-HDL-C also provides residual risk estimation in Taiwanese populations who have been already on statin therapy.116,117 Since the data of non-HDL-C is much easier to obtain than apoB in most hospitals or clinics in Taiwan, the level of non-HDL-C is recommended as a secondary target after LDL-C.10 The target of non-HDL-C is 30 mg/dL above the recommended LDL-C target. For example, if the LDL-C target is 100 mg/dL, the secondary target of non-HDL-C is 130 mg/dL. Given the essential implications of apoB in atherosclerosis, direct measurement of the circulating concentration of apoB to assess the risk also can be considered if the measurement is available in the laboratory. In the 2019 European lipid guideline, ApoB is recommended to be <65, 80, and 100 mg/dL for very-high, high-, and moderate-risk people, respectively.18 Since apoB cannot be measured in most hospitals or clinics and rarely used in clinical practice in Taiwan, no specific target for apoB is recommended in this guideline.

Recommendation Non-HDL-C and apoB can be used to predict the risk of ASCVD, especially for people with high TG (>150 mg/dL), DM, obesity, or metabolic syndrome. (COR IIa, LOE B) Non-HDL-C is used as the secondary target and the target of non-HDL-C is 30 mg/dL above the recommended LDL-C target. (COR IIa, LOE B)