2022-台灣高血脂初級預防指引-4. 風險分級

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

風險類別

高風險族群（糖尿病、慢性腎臟病和低密度脂蛋白膽固醇≥190 mg/dL）：本一級預防指南決定沿用傳統的目標值控制方法，低密度脂蛋白膽固醇的治療目標值根據心血管危險因子的存在情況進行調整。由於動脈粥狀硬化性心血管疾病是糖尿病和慢性腎臟病患者死亡的主要原因，因此這兩類患者被認為是高風險族群。糖尿病的診斷和糖尿病血脂異常的管理策略已在2017年台灣高風險患者血脂指南¹⁰中進行了描述。對於慢性腎臟病，蛋白尿是用於檢測和診斷慢性腎臟病的重要生物標記。蛋白尿是指尿液中白蛋白排泄量增加。非定時尿液樣本中的尿液白蛋白與肌酸酐比值 (UACR) 已取代 24 小時尿液白蛋白排泄量，成為測量蛋白尿的首選方法。 23e26 蛋白尿液定義為 UACR ≥ 30 mg/g，可進一步分為微量白蛋白尿 (UACR 30-300 mg/g) 和大量白蛋白尿 (UACR > 300 mg/g)。美國國家腎臟基金會腎臟疾病預後品質倡議（KDOQI）指引將慢性腎臟病（CKD）定義為腎損傷（尿液白蛋白/肌酸酐比值[UACR] ≥ 30 mg/g）或腎小球濾過率（GFR）< 60 mL/min/1.73 m²，且持續至少三個月。 ^27,28 GFR通常根據血清肌酸酐水平，以腎臟疾病飲食改良（MDRD）²⁹或慢性腎臟病流行病學協作組（CKD-EPI）³⁰方程式進行估算。對於合併糖尿病和非透析CKD的患者，建議立即進行降血脂治療。嚴重高膽固醇血症（定義為低密度脂蛋白膽固醇[LDL-C] ≥ 190 mg/dL）會增加動脈粥狀硬化性心血管疾病（ASCVD）和過早心血管事件的風險。這些族群罹患冠心病的風險比一般人高5至6倍，男性罹患冠心病的時間比一般人早10至20年，女性早20至30年。 ³¹早期開始降血脂治療可顯著降低這些族群的發生率和死亡率。 ³²低密度脂蛋白膽固醇（LDL-C）≥190 mg/dL顯著增加家族性高膽固醇血症（FH）的發生率。 LDL-C≥190 mg/dL的族群中約有7%可能符合FH的診斷標準。 ³³應考慮這類族群進行基因檢測以診斷FH。先前研究表明，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基因突變的受試者發生冠心病的風險高出6倍，而LDL-C≥190 mg/dL且同時攜帶FH基因突變的受試者發生冠心病的風險則高出sup.22</sup>202倍。由於LDL-C≥190 mg/dL是一個非常特殊且高風險的群體，具有顯著的長期臨床預後，因此被歸類為高風險族群。與糖尿病和慢性腎臟病一樣，由於這些患者的心血管風險極高，建議立即進行降血脂治療並強化LDL-C控制。

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.