2022-台灣高血脂初級預防指引-19-其他血脂數值控制目標 TG三酸甘油脂

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

三酸甘油酯

儘管極低密度脂蛋白 (VLDL) 和乳糜微粒都是富含三酸甘油酯 (TG) 的顆粒，但由於乳糜微粒的半衰期極短，VLDL 顆粒構成循環 TG 的絕大部分。此外，VLDL 顆粒大多直徑小於 70 nm，且含有載脂蛋白 B (apoB)，它們可能滯留在動脈壁上，並啟動動脈粥狀硬化過程。儘管 VLDL 顆粒具有致動脈粥樣硬化的潛力，但 TG 與動脈粥樣硬化性心血管疾病 (ASCVD) 之間的關聯仍未有定論。主要問題在於，在調整其他脂蛋白後，三酸甘油酯（TG）的預測能力微乎其微。 孟德爾遺傳學研究也觀察到了相同的結果。 對TG資料的解讀也應謹慎，因為TG與高密度脂蛋白膽固醇（HDL-C）、低密度脂蛋白膽固醇（LDL-C）或脂蛋白(a)有顯著相關性。 然而，儘管使用了他汀類藥物治療，人們仍然認為血清TG水平升高似乎與動脈粥狀硬化性心血管疾病（ASCVD）的殘餘風險有關。 PREDIMED研究的次要分析表明，極低密度脂蛋白（VLDL）顆粒及其殘餘顆粒與先前無ASCVD病史患者的心血管結果相關。 與降低LDL的藥物在預防ASCVD方面取得的巨大成功不同，幾乎所有降低TG的藥物在臨床試驗中均未能改善他汀類藥物治療下的心血管結果。 REDUCE-IT試驗評估了純化高劑量二十碳五烯酸（EPA）的療效。研究參與者為已確診動脈粥狀硬化性心血管疾病 (ASCVD) 或糖尿病且伴隨其他一項危險因子的患者，他們已接受他汀類藥物治療，空腹三酸甘油酯 (TG) 水平為 135～499 mg/dL，低密度脂蛋白膽固醇 (LDL-C) 水平為 41～100 mg/dL。患者被隨機分配至每日兩次服用 2 g 二十碳五烯酸乙酯或安慰劑組。經過中位數為 4.9 年的隨訪，二十碳五烯酸乙酯組的心血管事件風險較安慰劑組降低了 25%。值得注意的是，研究期間平均 LDL-C 水平未發生變化，顯示二十碳五烯酸乙酯的益處主要體現在降低 TG 水平。在 EVAPORATE 試驗中，與安慰劑相比，二十碳五烯酸乙酯也顯示出顯著降低冠狀動脈斑塊體積（透過電腦斷層掃描檢測）的效果。 

建議：對於已接受最大耐受劑量他汀類藥物治療且三酸甘油酯水平較高（>150 mg/dL）的ASCVD患者或伴隨1項危險因子的糖尿病患者，可考慮使用高劑量EPA（二十碳五烯酸乙酯）治療。 （COR IIa，LOE B）


Triglyceride

Although very low-density lipoprotein (VLDL) and chylomicrons are both TG-rich particles, VLDL particles constitute the majority of circulating TG because of the ultrashort half-life of chylomicron. Additionally, VLDL particles, which are mostly smaller than 70 nm in diameter and contain apoB, can potentially be retained in the arterial wall and initiate atherosclerotic processes. Despite the atherogenic potential of VLDL particles, the association between TG and ASCVD remains inconclusive. The major problem is the insignificant predicting power of TG after adjusting the other lipoproteins.118 The same results were also observed in the Mendelian genetic studies.119 Interpretation of the data about TG should also be cautious because there exists significant correlations of TG with HDL-C, LDL-C, or lipoprotein(a).120 However, it is still believed that elevated serum TG levels appear to be associated with a residual risk of ASCVD, despite the use of statin therapy. A secondary analysis from the PREDIMED study demonstrated that the VLDL particles and their remnant particles were associated with CV outcomes among patients without prior ASCVD.121 Unlike the great success of LDL-lowering agents in preventing ASCVD, almost all TG-lowering agents failed to improve CV outcome under statin therapy in the clinical trials. The REDUCE-IT trial evaluated the efficacy of purified high dose EPA. Study participants were patients with established ASCVD or diabetes with one additional risk factor and already received statin therapy with a fasting TG level of 135e499 mg/dL and LDL-C level of 41e100 mg/dL. The patients were randomized to 2 g of icosapent ethyl twice daily or placebo. After a median of 4.9 years followup, the icosapent ethyl group had 25% lower risk of CV events compared with the placebo group.122 Of note, the average LDL-C level did not change over the study period, indicating the benefit of isolated TG-driven effect. Icosapent ethyl also demonstrated significant effect on regression of coronary plaque volume detected by computed tomography compared with placebo in the EVAPORATE trial.123

Recommendation High dose EPA (icosapent ethyl) therapy can be considered for patients with ASCVD or with diabetes and
1 risk factor who are already on maximally tolerated statin therapy with high TG level (>150 mg/dL). (COR IIa, LOE B)