血脂调整与脑卒中的预防课件

,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,医学ppt,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,医学ppt,*,血脂调整与脑卒中的预防,复旦大学上海医学院中山医院神经内科,汪 昕,1,医学ppt,脑卒中在中国,MONICA,研究：我国患病率低于日本，芬兰等高发区，而高于大多数工业化和发展中国家，位于前列。,我国脑卒中的患病率、死亡率在疾病谱中一直处于前三位。,全国脑卒中年发病率约为,110180/10,万；年死亡率约为,80120/10,万,(,城市人口患病率约为,600700/10,万；农村人口患病率约为,300/10,万）,脑卒中是死亡的主要原因之一，超过70%的幸存者伴不同 程度的功能障碍(残疾)。,医疗卫生人员心血管病防治知识 陶寿淇，武阳丰主编,研究背景,2,医学ppt,脑卒中的年龄性别死亡率,(1999),来源：中国卫生统计提要,1999,研究背景,3,医学ppt,北京,25-74,岁人群急性脑卒中标化发病率,王文化，等，中华流行病学杂志,2001(4),：,269-271,研究背景,4,医学ppt,卒中危险性下降,随访时间（年）,发生事件患者的比例,安慰剂,药物治疗*,危险性下降,28%,(95%,的可信限,17-38%),P0.0001,Reference:,Lancet,2001;358:1033-41,0.20,0.15,0.10,0.05,0.00,1,2,3,4,研究背景,5,医学ppt,显著降低中风事件,0.06,0.05,0.04,0.03,0.02,0.01,Kaplan.Meier Rates,雷米普利,安慰剂,0 500 1000 1500,天,相对危险性降低,=32%,(44%-16%),P6 mo,一级预防,二级预防,心脏保护研究,4,稳定,CAD,MIRACL,AFCAPS/TexCAPS/WOSCOPS,Duration of follow-up:,1,5.0 years;,2,6.1 years;,3,5.4 years;,4,XXyears.,Randomization:2496 h,CARE,1,/LIPID,2,Randomization:CARE-320 moLIPID-336 mo,16,医学ppt,HPS,设计,5年,N=20,536,例患者(3,280例有脑血管疾病，17,256例患者有其他阻塞性动脉疾病或不合并脑血管疾病的糖尿病),舒降之 40,mg，,或相匹配的安慰剂治疗,LDL,胆固醇水平平均相差1.0,mmol/L(39 mg/dL),17,医学ppt,参加,HPS,病人的基线特点,18,医学ppt,基线血脂,(mmol/L),和载脂蛋白,(g/L),19,医学ppt,治疗安排,20,医学ppt,结 果,21,医学ppt,(10269),(10267),辛伐他汀,安慰剂,RR&95%CI,他汀更好,安慰剂更好,类型,290,409,缺血性,51,53,出血性,103,134,不明,严重性,96,119,致死性,42,51,严重,107,155,中度,138,189,轻度,61,71,不明,(4.3%),(5.7%),25%SE 5,减少,444,585,(2P0.00001),所有卒中,0.4,0.6,0.8,1.0,1.2,1.4,HPS:,卒中发病率,结果,1,22,医学ppt,辛伐他汀,安慰剂,RR&95%CI,他汀更好,安慰剂更好,基础,特征,(10269),(10267),年龄(岁),65,164,195,(3.3%),(4.0%),65 70,110,154,(4.5%),(6.3%),70,170,236,(5.8%),(8.2%),性别,男,331,453,(4.3%),(5.9%),女,113,132,(4.4%),(5.2%),所有病人,444,585,(4.3%),(5.7%),25%SE 5,减少,(2P0.00001),0.4,0.6,0.8,1.0,1.2,1.4,HPS:,按年龄、性别的卒中发病率,结果,2,23,医学ppt,辛伐他汀,安慰剂,RR&95%CI,他汀更好,安慰剂更好,基础,特点,(10269),(10267),既往 冠心病,是,265,347,(4.0%),(5.2%),否,179,238,(5.0%),(6.7%),既往脑血管病,是,169,170,(10.3%),(10.4%),否,275,415,(3.2%),(4.8%),既往糖尿病,是,149,193,(5.0%),(6.5%),否,295,392,(4.0%),(5.4%),所有病人,444,585,(4.3%),(5.7%),25%SE 5,减少,(2P0.00001),0.4,0.6,0.8,1.0,1.2,1.4,HPS:,按既往疾病的卒中发病率,结果,3,24,医学ppt,辛伐他汀,安慰剂,RR&95%CI,他汀更好,安慰剂更好,基线,特征,(10269),(10267),既往冠心病,是,175,237,(2.6%),(3.5%),否,115,172,(3.2%),(4.8%),既往脑血管病,是,100,122,(6.1%),(7.5%),否,190,287,(2.2%),(3.3%),既往糖尿病,是,102,140,(3.4%),(4.7%),否,188,269,(2.6%),(3.7%),所有病人,290,409,(2.8%),(4.0%),30%SE 6,减少,(2P0.00001w4),0.4,0.6,0.8,1.0,1.2,1.4,HPS:,按既往疾病的 缺血性卒中,结果,4,25,医学ppt,辛伐他汀,安慰剂,RR&95%CI,他汀更好,安慰剂更好,基线,特点,(10269),(10267),既往冠心病,是,1459,1841,(21.8%),(27.5%),否,574,744,(16.1%),(20.8%),既往脑血管病,是,406,488,(24.7%),(29.8%),否,1627,2097,(18.9%),(24.3%),既往糖尿病,是,601,748,(20.2%),(25.1%),否,1432,1837,(19.6%),(25.2%),所有病人,2033,2585,(19.8%),(25.2%),24%SE 3,减少,(2P0.00001),0.4,0.6,0.8,1.0,1.2,1.4,HPS:,按既往疾病的主要血管事件,结果,5,26,医学ppt,主要血管事件的绝对效果以及按既往脑血管病的卒中,S,S,P,P,Yes No,既往脑血管病,主要血管事件(%),相对减少(,SE):,绝对比例/1000,P-value,20%(6)58(18)p=0.001,25%(3)60(7)p0.0001,其他事件,卒中,结果,6,27,医学ppt,辛伐他汀,安慰剂,RR&95%CI,他汀更好,安慰剂更好,基线,特点,(10269),(10267),LDL,胆固醇(,mmol/L),3.0,137,194,(4.0%),(5.7%),3.0 3.5,199,236,(4.6%),(5.4%),HDL,胆固醇(,mmol/L),0.9,170,199,(4.7%),(5.6%),0.9 1.1,159,220,(4.1%),(5.7%),所有病人,444,585,(4.3%),(5.7%),25%SE 5,减少,(2P0.00001),0.4,0.6,0.8,1.0,1.2,1.4,HPS:,按基线血脂的卒中发病率,结果,7,28,医学ppt,辛伐他汀,安慰剂,RR&95%CI,他汀更好,安慰剂更好,基线,特点,(10269),(10267),舒张压(,mmHg),80,176,239,(3.9%),(5.2%),80 90,131,185,(4.0%),(5.8%),90,137,160,(5.6%),(6.5%),收缩压(,mmHg),140,162,189,(3.6%),(4.2%),140 160,121,169,(3.9%),(5.3%),160,161,226,(6.1%),(8.8%),所有病人,444,585,(4.3%),(5.7%),25%SE 5,减少,(2P0.00001),0.4,0.6,0.8,1.0,1.2,1.4,HPS:,按基线血压的卒中发病率,结果,8,29,医学ppt,辛伐他汀,安慰剂,RR&95%CI,他汀更好,安慰剂更好,基线,特点,(10269),(10267),高血压治疗,是,223,274,(5.3%),(6.5%),否,221,311,(3.6%),(5.2%),阿斯匹林,是,286,378,(4.4%),(5.8%),否,158,207,(4.2%),(5.5%),所有病人,444,585,(4.3%),(5.7%),25%SE 5,减少,(2P0.00001),0.4,0.6,0.8,1.0,1.2,1.4,HPS:,按高血压治疗和使用阿斯匹林卒中发病率,结果,9,30,医学ppt,辛伐他汀,安慰剂,RR&95%CI,他汀更好,安慰剂更好,随访年,(10269),(10267),1,87,106,(0.8%),(1.0%),2,81,132,(0.8%),(1.3%),3,82,111,(0.8%),(1.2%),4,81,111,(0.9%),(1.2%),5+,113,125,(1.2%),(1.4%),所有病人,444,585,(4.3%),(5.7%),25%SE 5,减少,(2P0.00001),0.4,0.6,0.8,1.0,1.2,1.4,HPS:,按年卒中的发病率,结果,10,31,医学ppt,随访年限,安慰剂,辛伐他汀,效益/1000(,SE),2(1),7(2),10(2),13(3),14(4),15(10),Logrank p0.0001,0,1,2,3,4,5,6,0,1,2,3,4,5,6,7,卒中比例,HPS:,按年卒中,结果,11,32,医学ppt,HPS:Adverse Events,结果,12,33,医学ppt,他汀,安慰剂,RR,&95%CI,STATIN better,PLACEBO better,研究,GREACE,9,17,(1.1%),(2.1%),AFCAPS/TexcAPS,14,17,(0.4%),(0.5%),Post-CABG,18,16,(2.7%),(2.4%),GISSI,20,19,(0.9%),(0.9%),WOSCOPS,46,51,(1.4%),(1.5%),CARE,52,76,(2.5%),(3.7%),SSSS,56,76,(2.5%),(3.4%),ASCOT,89,121,(1.7%),(2.4%),PROSPER,135,131,(4.7%),(4.5%),LIPID,169,204,(3.7%),(4.5%),ALLHAT,209,231,(4.0%),(4.5%),HPS,444,585,(4.3%),(5.7%),所有病人,1261,1544,(3.0%),(3.6%),21%SE 4,减少,(2P0.00001),0.4,0.6,0.8,1.0,1.2,1.4,主要他汀试验的卒中影响,34,医学ppt,Mechanisms of Action,Lipid lowering is not the entire answer,Benefits seen in patients with relatively normal levels,Plaque stabilization,Anticoagulant