Bài giảng Kiểm soát nguy cơ tim mạch trên bệnh nhân rối loạn lipid máu - TS.BS. Nguyễn Thanh Huân

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Bài giảng Kiểm soát nguy cơ tim mạch trên bệnh nhân rối loạn lipid máu do TS.BS. Nguyễn Thanh Huân trình bày các nội dung: Xơ vữa động mạch; Non-HDL-c và nguy cơ biến cố bệnh tim mạch; Khuyến cáo xét nghiệm bilan lipid máu ở bệnh nhân ĐTĐ; Khuyến cáo mục tiêu điều trị rối loạn lipid máu; Omega-3 hỗn hợp không mang lại lợi ích tim mạch.

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CHƯƠNG TRÌNH ĐÀO TẠO LIÊN TỤC Thành tựu khoa học – Đổi mới Thời gian: 12/11/2022, 9:40 – 10:00, Hội trường 6 (HT 4D) Kiểm soát nguy cơ tim mạch trên bệnh nhân rối loạn lipid máu TS.BS. Nguyễn Thanh Huân Bộ môn Lão khoa – ĐHYD TP.HCM
Tử vong do các bệnh tim mạch trên thế giới Nat Rev Dis Primers 5, 56 (2019). https://doi.org/10.1038/s41572-019-0106-z 2
Các yếu tố nguy cơ bệnh tim mạch ở người Việt Nam 2,130 adults ≥ 25 years old Int J Hypertens . 2012;2012:560397. doi: 10.1155/2012/560397. 3
Low density lipoprotein cholesterol (LDL-c) LDL-c và biến cố bệnh mạch vành LDL-c là mục tiêu điều trị tiên phát Lionel Opie Bernard Gersh. Drugs for the Heart 8th Edition. 2013 2019 ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J . 2020 Jan 1;41(1):111-188. 4
≥ ≥ ≥ ≥ 5,582 4,868 862 780 18.0 18.4 1.01 (0.92-1.11) 1.10 (1.00-1.21) 0.6 0.8 All-Cause Mortality 0.6 0.8 1.0 1.0 1.2 1.2 1.4 1.4 Non-HDL Non-HDL LDL Values According to Median Individuals Events Apolipoprotein B and Non-HDL Cholesterol Better Reflect Event Rate apoB Cholesterol Cholesterol Cholesterol < LDL < 5,679 Residual Risk Than LDL Cholesterol in Statin-Treated Patients 1,231 Per27.7 1,000 Hazard Ratio 1.00 < apoB < Cholesterol 5,431 1,239 Person Years 28.8 1.00 (95% CI) E < ≥ 836 965 107 167 16.0 22.0 Camilla Ditlev Lindhardt Johannesen, Martin Bødtker Infarction By Langsted, Børge Grønne (0.62-0.92) 0.75 Nordestgaard F I G U R< 2 Multivariable-Adjusted Hazard Ratios of All-Cause Mortality and Myocardial Mortensen, AnneDiscordant Versus Concordant ≥ 0.97 (0.82-1.14) ≥ < ≥ < < 4,836717 1,037 175 1,089 and 28.8 231 Categories of Apolipoprotein B, LDL Cholesterol, 28.3 25.7 Non-HDL Cholesterol in Statin-Treated Patients 1.21(1.02-1.36) (1.03-1.41) 1.181.00 ≥ < ≥ ≥ 5,783 1,679 5,582 986 249 862 19.6 18.7 18.0 1.01 (1.03-1.23) 1.13 (0.92-1.11) 0.86 (0.75-0.99) Copenhagen General Population Study. 13,015 statin-treated patients. 8 years median follow-up ≥ < 1,632 381 26.9 1.21 (1.07-1.36) ≥ ≥ 4,868 780 0.6 18.4 0.6 0.8 0.8 1.0 1.0 1.2 1.2 1.4 1.4 1.10 (1.00-1.21) All-Cause Mortality Hazard Ratio (95% Confidence Interval) Non-HDL 0.6 0.8 1.0 1.2 1.4 Values According to Median Individuals Events Event Rate apoB Cholesterol Non-HDL LDL LDL Per27.7 Myocardial Infarction 1,000 Hazard Ratio < < 5,679 1,231 1.00 Cholesterol Cholesterol apoB Cholesterol Person Years (95% CI) < ≥ 836 107 16.0 0.75 (0.62-0.92) Values According to Median Individuals Events < < 5,431 1,239 Event Rate 28.8 1.00 ≥ < < 717 4,836 175 1,089 28.3 28.8 1.21 (1.03-1.41) 1.00 < ≥ < ≥ LDL ≥ 965 1,679 5,783 167 249 986 22.0 Per19.6 1,000 18.7 0.86 (0.82-1.14) 0.97(0.75-0.99) Hazard Ratio 1.13 (1.03-1.23) ≥ apoB ≥ < Cholesterol < 1,037 1,632 231 25.7 381 Person Years 26.9 1.18 (1.02-1.36) (95% CI) 1.21 (1.07-1.36) ≥ ≥ ≥ ≥ 5,582 4,868 862 780 18.0 0.6 18.4 0.8 1.0 1.2 1.4 1.01 (1.00-1.21) (0.92-1.11) 1.101.00 < < 4,044 184 6.0 < ≥ 1,509 52 4.4 0.6 Hazard Ratio (95%1.0 Confidence Interval) 0.94 (0.69-1.29) 0.8 1.2 1.4 ≥ < 1,367 92 8.0 1.49 (1.15-1.92) Non-HDL ≥ Non-HDL LDL ≥ 4,445 209 5.5 1.24 (1.01-1.52) apoB Myocardial Infarction Cholesterol Cholesterol < < < < 5,679 5,431 1,231 Values According to Median Individuals Events 1,239 Event Rate 0.6 27.7 28.8 1.0 1.4 1.8 2.2 1.00 < < Non-HDL ≥ ≥ LDL 836 965 107 167 16.0 22.0 0.75 (0.62-0.92) 0.97 (0.82-1.14) LDL Per 1,000 Hazard Ratio ≥ ≥ < < Cholesterol Cholesterol Cholesterol 717 1,037 175 28.3 231 Person Years 25.7 1.21 (1.03-1.41) 1.18 (1.02-1.36) apoB (95% CI) ≥ ≥ 5,783 5,582 986 862 19.6 18.0 1.13 (1.03-1.23) 1.01 (0.92-1.11) < < < < 4,524 4,044 207 184 5.9 6.0 1.00 < < ≥ ≥ 859 1,509 31 52 4.6 4.4 0.6 0.8 1.0 1.2 1.4 0.94 (0.69-1.29) 0.97 (0.66-1.41) ≥ ≥ < < 887 1,367 69 92 9.3 8.0 1.49 (1.15-1.92) 1.78 (1.35-2.34) Non-HDL Hazard Ratio (95% Confidence Interval) ≥ ≥ ≥ ≥ 5,095 4,445 230 209 5.4 5.5 1.24 (1.01-1.52) 1.20 (0.99-1.46) apoB Cholesterol < < 5,679 1,231 Myocardial Infarction 27.7 0.6 1.0 1.4 1.8 2.2 1.00 < ≥ Non-HDL 836 107 16.0 0.75 (0.62-0.92) Non-HDL LDL Values According to Median Individuals Events Event Rate ≥ < 717 175 28.3 1.21 (1.03-1.41) CollapoB . Cholesterol Cholesterol J AmCholesterol2021 Mar 23;77(11):1439-1450. doi: 10.1016/j.jacc.2021.01.027. Cardiol 5 ≥ ≥ LDL 5,783 986 Per19.6 1,000 1.13 (1.03-1.23) Hazard Ratio < <
Nguy cơ tử vong và NMCT vẫn cao mặc dù kiểm soát được LDL-c nhưng chưa kiểm soát được non-HDL-c ở bệnh nhân đang được điều trị với statin Kiểm soát LDL-c là chưa đủ để phòng ngừa biến cố tim mạch cho bệnh nhân ĐTĐ có rối loạn lipid máu
CENTRAL I LL USTRATI O N Multivariable-Adjusted Risk of All-Cause Mortality and Myocardial Non-HDL-cStatin-Treated Patients From the Copenhagen General Population Study Infarction in 13,015 là gì? HDL LDL Discordant values compared to concordant low values Lp(a) LDL No increased risk of Non-HDL/ mortality or MI ApoB IDL Non-HDL LDL 18%-21% risk of mortality VLDL Non-HDL/ ApoB 49%-78% risk of MI LDL Chylomicrons 23% risk of mortality Non-HDL 82% risk of MI ApoB ApoB Cholesterol Triglyceride LDL-c = TC – HDL-c – (Triglyceride/5) (mg/dL). Cholesterol TP = HDL-c + LDL-c + IDL-c + VLDL-c 7 J AmJohannesen, 2021 Mar 23;77(11):1439-1450. doi: 10.1016/j.jacc.2021.01.027. Coll Cardiol . C.D.L. et al. J Am Coll Cardiol. 2021;77(11):1439–50.
Xơ vữa động mạch: vai trò của non-HDL-c VLDL Lipoprotein lipase Chylomicron quá lớn để vào lớp nội mạc IDL rất thấp và không đáng kể FFA=free fatty acids, LPL=lipoprotein lipase. Lancet . 2014 Aug 16;384(9943):626-635. doi: 10.1016/S0140-6736(14)61177-6. 8
Non-HDL-c và nguy cơ biến cố bệnh tim mạch 398 846 individuals During a maximum follow-up of 43·6 years Lancet . 2019 Dec 14;394(10215):2173-2183. doi: 10.1016/S0140-6736(19)32519-X. 9
160-179 20 21 22 23 25 26 28 29 23 27 32 37 26 31 36 41 140-159 18 19 20 21 23 24 25 26 21 25 29 34 24 28 33 38 80-84 120-139 16 17 18 19 20 21 22 23 19 22 26 31 22 25 30 34 Vị trí non-HDL-c trong đánh giá nguy cơ tim mạch 20 100-119 160-179 15 15 16 17 15 15 16 17 18 19 20 21 21 22 23 24 17 20 24 28 19 21 24 27 19 23 27 31 24 27 31 34 Eu do 140-159 13 13 14 15 18 19 20 21 16 18 21 23 21 23 26 30 75-79 2019 120-139 SCORE2 & 11 12 13 11 SCORE2-OP 16 17 18 15 10-year risk of 9 10 and non-fatal) CV 15 15 100-119 (fatal 10 11 13 14 2021 15 18 50-69 18 20 ≥70 years 14
Tăng non-HDL-c đặt biệt được ghi nhận ở các bệnh nhân đái tháo đường, tăng triglyceride, hội chứng chuyển hóa, béo phì hoặc nồng độ LDL-c rất thấp
Khuyến cáo xét nghiệm bilan lipid máu ở bệnh nhân ĐTĐ Eu do 2019 ESC/ of dyslipid cardiovasc The Task Forc European Soci Atheroscleros Authors/Task For Colin Baigent* (C (Chairperson) (Ita (Italy), Lina Badim (Belgium), Victor Ian M. Graham (Ir (Germany), Boris Gabriele Riccardi States of America Olov Wiklund1 (S The three chairpersons contributed e *Corresponding authors: Franc Ma ¸ois Fax: þ41 223 727 229, Email: francoi Oxford OX3 7LF, United Kingdom. T and Biomolecular Sciences, Universit Email: alberico.catapano@unimi.it. ESC Committee for Practice Guidelin 2019 ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J . 2020 Jan 1;41(1):111-188. 1 12 Representing the EAS. ESC entities having participated
Khuyến cáo mục tiêu điều trị rối loạn lipid máu Eu do 2019 ESC/ LDL-c là mục tiêu điều trị thứ nhất dyslipid of cardiovasc Non-HDL-c là mục tiêu điều trị thứ hai The Task Forc European Soci Atheroscleros Authors/Task For Colin Baigent* (C (Chairperson) (Ita (Italy), Lina Badim (Belgium), Victor Ian M. Graham (Ir (Germany), Boris Gabriele Riccardi States of America Olov Wiklund1 (S The three chairpersons contributed e *Corresponding authors: Franc Ma ¸ois Fax: þ41 223 727 229, Email: francoi Oxford OX3 7LF, United Kingdom. T and Biomolecular Sciences, Universit Email: alberico.catapano@unimi.it. ESC Committee for Practice Guidelin 2019 ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J . 2020 Jan 1;41(1):111-188. 1 13 Representing the EAS. ESC entities having participated
Khuyến cáo mục tiêu điều trị rối loạn lipid máu Eu do 2019 ESC/ of dyslipid cardiovasc The Task Forc European Soci Atheroscleros Authors/Task For Colin Baigent* (C (Chairperson) (Ita (Italy), Lina Badim (Belgium), Victor Ian M. Graham (Ir (Germany), Boris Gabriele Riccardi States of America Olov Wiklund1 (S The three chairpersons contributed e *Corresponding authors: Franc Ma ¸ois Fax: þ41 223 727 229, Email: francoi Oxford OX3 7LF, United Kingdom. T and Biomolecular Sciences, Universit Email: alberico.catapano@unimi.it. ESC Committee for Practice Guidelin 2019 ESC/EAS Guidelines for the management of dyslipidaemias. Eur Heart J . 2020 Jan 1;41(1):111-188. 1 14 Representing the EAS. VTM2183048 having participated ESC entities
Tỷ lệ đạt mục tiêu lipid máu ở người Việt Nam có ĐTĐ 733 older patients with T2DM and a very high CVD risk 100% 90% 80% 70% 60% 89.2% 87.9% 56.2% 50% 40% 30% 20% 43.8% 10% 10.8% 12.1% 0% LDL-c < 1.4 mmol/L non-HDL-c
Làm thế nào để kiểm soát tốt hơn nguy cơ biến cố tim mạch liên quan đến rối loạn lipid máu? Làm cách nào kiểm soát non-HDL-c? 16
2015 Khuyến cáo điều trị tăng triglyceride theo Hội Tim Mạch Việt Nam Triglyceride Triglyceride 200-499 mg/dl ≥ 500mg/dl Phòng ngừa biến cố tim mạch Phòng ngừa viêm tụy cấp 150 – 200 mg/dl: thay đổi lối sống 200 – 499 mg/dl: thay đổi lối sống + tính non-HDL-c và điều trị theo mục tiêu non-HDL-c ≥ 500 mg/dl: thay đổi lối sống + thuốc giảm TG để phòng ngừa viêm tụy cấp Khuyến cáo Chẩn đoán và điều trị rối loạn lipid máu 2015 – Hội Tim Mạch Học Việt Nam 17
. . t 4.6.4. Important groups . . 2021 ESC Guidelines on cardiovascular disease 148 Recommendations for drug treatments of patients with . g . ESC/EAS Guidelines prevention in clinical practicehypertriglyceridaemia. . . v Eu do Downloaded from https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehab484/6358713 by guest on 04 Septembe . . outcomes.354 Recently, the REDUCE-IT trial194 demonstrated that in . . . . among these, FH is the most common and is strongly related to CVD . statin-treated patients with high CV risk with fasting TG levels . . Developed by the Task Force for cardiovascular disease prevention . between 135À499 mg/dL (1.52À1.63 mmol/L), high-dose icosapent . . < (Table 11). In general, in a patient with dyslipidaemia, the pattern of . inheritance commonly does not suggest that there is a major single . . Recommendations . ethyl, a highly purified and stable EPA (2 g) taken b.i.d., significantly in clinical practice with representatives of the European Society of . . Classa Level b 2019 ESC/ . . p gene (monogenic) disorder causing the abnormality; rather, it stems Cardiology and 12 medical societies . reduced the risk of ischaemic events, including CV death, by about . . . one-quarter over a median follow-up of 4.9 years. In addition, the . from the inheritance of more than one gene variant affecting lipopro- . tein metabolism that, on its own, might have relatively little effect, but . . . VITAL trial showed that n-3 fatty acids at the lower dose of 1 g/day With the special contribution of the European Associationas the ﬁrst Statin treatment is recommended of . . of dyslipid . ( in combination with another or others has a greater influence on TC, . . were not effective for primary prevention of CV or cancer events . . . among healthy middle-aged men and women over 5 years of follow- . cardiovasc . TGs, or HDL-C. The pattern of inheritance is polygenic.357 It is com- . g mon to find that high LDL-C, high TG, or low HDL-C levels affect Preventive Cardiology (EAPC) choice for reducing CVD risk in high-risk drug of ... . up.333 Recommendations for the treatment of HTG are shown . I . several family members. A .Forc The Task . s below. . . Authors/Task Force Members: Frank L.J. Visseren* (Chairperson) (Netherlands), individuals . with hypertriglyceridaemia [triglycer- . . Downloaded from https://academic.oup.com/eurheartj/article-abstract/41/1/111/5556353 by guest on Franc . . ¸ois Mach* (Chairperson) (Switzerland), Yvo M. Smulders (Task Force . . . 533 . † 9.1.1 Familial combined hyperlipidaemia European Soci. . Coordinator) (Netherlands), David Carballo (Task (200 mg/dL)]. ides >2.3 ... .mmol/LForce Coordinator) Recommendations for drug treatment of patients with hypertriglyceridaemia . (Switzerland), Konstantinos C. Koskinas (Switzerland), Maria B€ck (Sweden), a † . Familial combined hyperlipidaemia (FCH) is a highly prevalent mixed . dyslipidaemia (1:100À200) characterized by elevated levels of LDL- Atheroscleros • On Statin Recommendations 8 Athanase Benetos (France), Alessandro Biffi . . In patients.... taking statins who areBoavida . ´-Manuel at LDL-C goal Classa Levelb (Italy), Jose is7,10 . C, TGs, or both, and is an important cause of premature CAD. FCH . a complex disease, and the phenotype is determined 9 the interac- by Statin treatment is recommended as the ﬁrst . (Portugal), Davide Capodanno (Italy), Bernard Cosyns (Belgium), Carolyn Crawford . . tion of multiple susceptibility genes and the environment. It has con- Authors/Task For . • At LDL-c goal . (Northern Ireland), Constantinos H.triglycerides >2.3 mmol/L (200 mg/dL), fenoﬁ- with Davos (Greece), Ileana Desormais (France), . drug of choice to reduce CVD risk in high-risk . IIb B . siderable overlap with the dyslipidaemic phenotypes of T2DM and Colin Baigent* (C . . individuals with hypertriglyceridaemia [TG lev- • High TG . . I B 534À536 . MetS. Even within a family, the phenotype shows high inter- and intra- .Badim (Chairperson) (Ita personal variability based on lipid values (TGs, LDL-C, HDL-C, and (Italy), Lina. . Emanuele Di Angelantonio (United Kingdom), Oscar H. Franco (Switzerland), Sigrun els >2.3 mmol/L (>200 mg/dL)].355 brate or bezaﬁbrate may be considered. . . 13 ApoB). FCH has no monogenic component and is not linked to a sin- . (United Kingdom), Monika Hollander . In high-risk (or above) patients with TG levels Halvorsen (Norway), F. D. Richard Hobbs . . . . . gle genetic cause, but the phenotype is high LDL-C and/or high (Belgium), Victor between 1.5À5.6 mmol/L (135À499 mg/dL) In high-risk . . (or above) patients with triglycerides (Netherlands), Ewa A. Jankowska (Poland), Matthias Michal (Germany), Simona . despite statin treatment, n-3 PUFAs (icosapent . IIa B . . Ian M. Graham (Ir 11 TGs.358,359 Therefore, the diagnosis is commonly missed in clinical practice; the combination of ApoB 2 >120 mg/dL and TGs >1.5 mmol/ (Germany),.Boris 6 . Sacco (Italy), Naveed Sattar (United Kingdom), Lale Tokgozoglu (Turkey), ethyl 2Â2 g/day) should be considered in . . combination with a statin.194 .. . >1.5 mmol/L (135 mg/dL) despite statin treat- Serena Tonstad (Norway), Konstantinos P .Tsioufis (Greece), Ineke van Dis . 5 . L (>133 mg/dL) with a family history of premature CVD can be used . to identify people who most probably have FCH.360 3 In primary prevention patients who are at . . . (Netherlands), Isabelle C. van Gelder (Netherlands), Christoph Wanner (Germany), LDL-C goal with TG levels >2.3 mmol/L . ment and..... lifestyle measures, n-3 PUFAs (icosa- IIb . Gabriele Riccardi The concept of mixed dyslipidaemia is also valuable clinically in . 4 assessing CV risk. It emphasizes both the importance of considering B . States of America ESC 2021 Bryan Williams (United Kingdom), ESC Scientific Document Group (>200 mg/dL), fenoﬁbrate or bezaﬁbrate may IIb B be considered in combination with . . pent ethyl 2 Â 2 g/day) may be considered in . . family history in deciding how rigorously to treat dyslipidaemia and Olov Wiklund (S . that elevated LDL-C levels portend a higher risk when HTG is also 1 *statins.305À307,356 . . . . Corresponding authors: The two chairpersons contributed equally to the document. Frank Visseren, Department of Vascular Medicine, University Medical Center Utrecht, . present. Statin treatment decreases CV risk by the same relative . Heidelberglaan 100, 3584 CX Utrecht, Netherlands. Tel: þ31 (0)88 7557324, E-mail: F.L.J.Visseren@umcutrecht.nl. Franc Mach, Cardiology Department, Geneva University Hospital, In high-risk patients who are at LDL-C goal . ¸ois . The three chairpersons contributed e Perret-Gentil 4, 1211 Geneva, Switzerland. Tel: þ41 (0)22 372 71 92, E-mail: francois.mach@hcuge.ch. † The people force coordinators contributed equally to the document. abso- . amount in two task with HTG as in those without. Because the . 84 combination with a statin. with TG levels >2.3 mmol/L (>200 mg/dL), . . Author/Task Force Member afﬁliations: listed in AuthorIIb . information. C . lute risk is often greater in those with HTG, they may therefore bene- *Corresponding authors: Franc Ma ¸ois fenoﬁbrate or bezaﬁbrate may be considered . . . ESC Clinical Practice Guidelines Committee (CPG): listed in the Appendix. in combination with statins.305À307,356 . . fit greatly from LDL-lowering therapy. . Fax: þ41 223 727 229, Email: francoi Oxford OX3 7LF, United Kingdom. T . . . CVD = cardiovascular disease; LDL-C = low-density lipoprotein cholesterol; . ESC subspecialty communities having participated in the development of this document. Associations: Association of Cardiovascular Nursing & Allied . . Professions (ACNAP), European Association low-density lipoprotein cholesterol;European Association of Preventive Cardiology (EAPC), European Heart Rhythm Association CVD = cardiovascular disease; LDL-C = of Cardiovascular Imaging (EACVI), . and Biomolecular Sciences, Universit Email: alberico.catapano@unimi.it. a . . PUFA = polyunsaturated fatty acids; TG = triglyceride. . . Vascular Biology, Cardiovascular Pharmacotherapy. Class of recommendation. Eur Heart J . 2021 Sep 7;42(34):3227-3337. doi: 10.1093/eurheartj/ehab484. PUFA = polyunsaturated fatty acid. . 18 . (EHRA), Heart Failure Association (HFA). Councils: Council on Valvular Heart Disease. Working Familial hypercholesterolaemia 9.1.2 Groups: Aorta and Peripheral Vascular Diseases, Atherosclerosis and . 9.1.2.1 Heterozygous familial hypercholesterolaemia. FH is a common ESC Committee for Practice Guidelin 1 Representing the EAS. b Level of evidence. Patient Forum . . . . a . codominant monogenic dyslipidaemia causing premature CVD due The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of . ESC entities having participated
Atherosclerosis . 2021 May;325:99-109. doi: 10.1016/j.atherosclerosis.2021.03.039. 19
Omega-3 hỗn hợp không mang lại lợi ích tim mạch Meta-analysis of 10 trials 77,917 individuals JAMA Cardiol. 2018;3:225-234. 20