降血脂药物在急性冠心症及脑中风的使用详解课件

Use of Lipid-lowering Agent in Acute Coronary Syndrome and Ischemic Stroke in TaiwanYi-Heng Li,MD,PhDYi-Heng Li,MD,PhDDepartment of Internal MedicineDepartment of Internal MedicineCollege of MedicineCollege of MedicineNational Cheng Kung UniversityNational Cheng Kung University降血脂药物在急性冠心症及脑中风的使用详解课件Liao JK.Liao JK.Am J CardiolAm J Cardiol.2005;96(suppl 1):24F-33F.2005;96(suppl 1):24F-33F.MMPs=matrix metalloproteinasesMMPs=matrix metalloproteinases Platelet activation Platelet activation Coagulation Coagulation Endothelial Endothelial progenitor cells progenitor cells Effects on Effects on collagencollagen MMPs MMPs AT AT1 1 receptor receptor VSMC proliferation VSMC proliferation Endothelin Endothelin Macrophages Macrophages Inflammation Inflammation Immunomodulation Immunomodulation Endothelial function Endothelial function Reactive oxygen Reactive oxygen species species NO bioactivity NO bioactivityPleiotropic effects of statinsStatinsLiao JK.Am J Cardiol.2005;96Statin in Acute Coronary SyndromeStatin in Acute Coronary SyndrMIRACL StudyRelative risk=0.84P=.04895%CI 0.701-0.999AtorvastatinPlacebo0510150481216Time Since Randomization(weeks)Cumulative Incidence(%)Time to first occurrence of:Death(any cause)Nonfatal MIResuscitated cardiac arrestWorsening angina with new objective evidence and urgent rehospitalization17.4%14.8%Primary Efficacy MeasureSchwartz GG,et al.JAMA.2001;285:1711-1718.Very early benefitVery early benefitMIRACL StudyRelative risk=0.Statin Use in ACS:NCKUH ExperiencelInclusion criteria:Inclusion criteria:-January 2000 December 2004January 2000 December 2004-patients admitted to the NCKUH with-patients admitted to the NCKUH with their first their first episode episode of acute coronary syndromeof acute coronary syndrome-Receive statin therapy before dischargeReceive statin therapy before dischargelExclusion criteria:Exclusion criteria:-Patients who received statin within 1 months -Patients who received statin within 1 months before admission before admission-Patients who did not receive statin after admission-Patients who did not receive statin after admission-loss f/u during one year-loss f/u during one year Li et al ACC 2007;Int Heart J 2007;48:677Li et al ACC 2007;Int Heart J 2007;48:677Statin Use in ACS:NCKUH ExperACS in NCKUH TotalTotal:符合符合符合符合 ICD-9 codeICD-9 code 共共共共 1248 1248 人次人次人次人次 其中住院期間有用其中住院期間有用其中住院期間有用其中住院期間有用 statinstatin 共共共共 480 480 人次人次人次人次11.1%42.7%39.6%48.9%42.1%Li et al 2007 ACC;Int Heart J 2007;48:677Li et al 2007 ACC;Int Heart J 2007;48:677ACS in NCKUH Total:符合 ICD-9 LDL Control Rate During One Year in ACS Patients(N=202)115 mg/dl 100 mg/dl 70 mg/dl115 mg/dl 100 mg/dl 70 mg/dl LDL-C Patients achieving goal(%)Patients achieving goal(%)35.530.2242426.426.46.33.8Early group Early group Late groupLate group Li et al 2007 ACC;Int Heart J 2007;48:677Li et al 2007 ACC;Int Heart J 2007;48:677LDL Control Rate During One Ye Event-Free Survival Analysis at 4 months follow upp=0.238p=0.238RR 1.73RR 1.73（95%CI 0.69-4.3395%CI 0.69-4.33）Event-Free Survival Analysis Statin in Acute Ischemic Stroke and Transient Ischemic AttackStatin in Acute Ischemic StrokStatin in Acute Ischemic Stroke and Transient Ischemic Attackl lRecommendations from the American Heart Association Recommendations from the American Heart Association(AHA)/American Stroke Association(ASA)suggest that(AHA)/American Stroke Association(ASA)suggest that statin therapy should be used in the vast majority of statin therapy should be used in the vast majority of patients with a history of ischemic stroke or TIA.patients with a history of ischemic stroke or TIA.l lHowever,it remains unclear as to how soon statin should However,it remains unclear as to how soon statin should be initiated after acute ischemic stroke.be initiated after acute ischemic stroke.l lStatin initiation during hospitalization for first ischemic Statin initiation during hospitalization for first ischemic stroke of atherosclerotic origin is probably justified stroke of atherosclerotic origin is probably justified based on ACS trialsbased on ACS trialsStatin in Acute Ischemic StrokTaiwan Stroke Registryl lTaiwan Stroke Registry,launched on May 1,2006 and engaging 37 hospitals around Taiwan,prospectively collected data of patients who developed acute stroke or TIA and were hospitalized within 10 days after onset.l lAll patients were followed up for at least 6 months after discharge.Taiwan Stroke RegistryTaiwan STaiwan Stroke Registry 8,429 pts with ischemic stroke or TIA All patients Pts with LAA&SVO Pts with CAD Hx All patients Pts with LAA&SVO Pts with CAD Hx 23%27%12%Percentage of pts receiving LLT at Percentage of pts receiving LLT at dischargedischarge Li et al 2008 AHALi et al 2008 AHATaiwan Stroke Registry Li et al 2008 AHALi et al 2008 AHADistribution of the Composite End Point at 6 Months Follow-upOverallOverallLLT use at LLT use at dischargedischargeNo LLT use No LLT use at dischargeat discharge(n=8429)(n=8429)(n=2001)(n=2001)(n=6428)(n=6428)Composite end Composite end points:points:567(7)567(7)91(5)91(5)476(7)*476(7)*All-cause mortality All-cause mortality348(4)348(4)41(2)41(2)307(5)307(5)Ischemic heart Ischemic heart disease disease13(0.13)13(0.13)1(0.05)1(0.05)12(0.19)12(0.19)Stroke Stroke224(3)224(3)52(2)52(2)172(3)172(3)Data are presented as numbers of patients(%);Data are presented as numbers of patients(%);*p0.001.*p0.001.Li et al 2008 AHEvent-Free Survival Analysis at 6 months Follow-upEvent-Free Survival Analysis at 6 months Follow-up Li et al 2008 AHALi et al 2008 AHAEvent-Free Survival Analysis aConclusionsl lHMGCoA reductase inhibitors(statins)are effective lipid-lowering drugs with clinical evidence to reduce vascular events.l lThere was a in-hospital under-prescription of statin in our acute coronary syndrome(ACS)and ischemic stroke(IS)patients.l lMore aggressive treatment of LDL is necessary in our ACS and IS patients.ConclusionsHMGCoA reductase inThank You for Your AttentionThank You for Your Attention