血脂治疗与临床指南

JNC7:ClassificationandManagementofBloodPressureforAdults**TreatmentdeterminedbyhighestBPcategory†TreatpatientswithchronickidneydiseaseordiabetestoBPgoalof130/80mmHg‡InitialcombinedtherapyshouldbeusedcautiouslyinthoseatriskfororthostatichypotensionSBP=systolicbloodpressure;DBP=diastolicbloodpressure;ACEI=angiotensin-convertingenzymeinhibitor;ARB=angiotensinreceptorblocker;BB=b-blocker;CCB=calciumchannelblockerJNC7.May2003.NIHpublication03-5233.InitialDrugTherapyBPClassificationSBP*(mmHg)DBP*(mmHg)LifestyleModificationWithoutCompellingIndicationsWithCompellingIndicationsNormal120and80EncourageNoantihypertensivedrugindicated.Drug(s)forcompellingindications.†Prehypertension120–139or80–89YesStage1hypertension140–159or90–99YesThiazide-typediureticformost.MayconsiderACEI,ARB,BB,CCB,orcombination.Drug(s)forcompellingindications.†Otherantihypertensivedrugs(diuretic,ACEI,ARB,BB,CCB)asneeded.Stage2hypertension160or100YesTwo-drugcombinationformost‡(usuallythiazide-typediureticandACEIorARBorBBorCCB).JNC7:TreatmentAlgorithmforHypertensionSBP=systolicbloodpressure;DBP=diastolicbloodpressure;ACEI=angiotensin-convertingenzymeinhibitor;ARB=angiotensinreceptorblocker;BB=b-blocker;CCB=calciumchannelblockerJNC7.May2003.NIHpublication03-5233.Optimizedosagesoraddadditionaldrugsuntilgoalbloodpressureisachieved.Considerconsultationwithhypertensionspecialist.NotatgoalbloodpressureWithoutcompellingindicationsStage1hypertension(SBP140–159orDBP90–99mmHg)Thiazide-typediureticformost.MayconsiderACEI,ARB,BB,CCB,orcombination.Stage2hypertension(SBP160orDBP100mmHg)Two-drugcombinationformost(usuallythiazide-typediureticandACEIorARBorBBorCCB).LifestylemodificationsNotatgoalbloodpressure(140/90mmHg)(130/80mmHgforthosewithdiabetesorchronickidneydisease)InitialdrugchoicesWithcompellingindicationsDrugsforcompellingindicationsOtherantihypertensivedrugs(diuretic,ACEI,ARB,BB,CCB)asneeded.ATPIII:NewFeaturesofGuidelines—FocusonMultipleRiskFactors•PersonswithdiabeteswithoutCHDraisedtolevelofCHDriskequivalent•Framingham10-yearabsoluteCHDriskprojectionsusedtoidentifycertainpatientswith2riskfactorsformoreintensivetreatment•Personswithmultiplemetabolicriskfactors(themetabolicsyndrome)identifiedascandidatesforintensifiedtherapeuticlifestylechanges(TLC)ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.ATPIII:NewFeaturesofGuidelines—ApplyingtheRecommendations•Completefastinglipoproteinprofile(TC,LDL-C,HDL-C,TG)recommendedaspreferredinitialtest•Useofplantstanols/sterolsandviscousfiberencouragedastherapeuticdietaryoptionstoenhanceLDL-Clowering•Strategiespresentedtoimproveadherencetotherapeuticlifestylechanges(TLC),drugtherapies•IntensiveTLCrecommendedforpersonswiththemetabolicsyndrome•Non–HDL-C(TCminusHDL-C)goalrecommendedassecondarytargetforpersonswithhighTGlevels(200mg/dL)ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.ATPIII:FeaturesSharedwithATPII•LDL-Cloweringremainsprimarygoaloftherapy•HighLDL-C(160mg/dL)consideredtargetforLDL-C–loweringdrugtherapy•IntensiveLDL-CloweringemphasizedinpersonswithCHD•3riskcategoriesfordifferentLDL-CgoalsandintensitiesofLDL-C–loweringtherapy•Subpopulations(otherthanmiddle-agedmen)identifiedfordetectionofhighLDL-C,clinicalintervention:youngadults;postmenopausalwomen;olderpersons•Weightloss,physicalactivityemphasizedtoreduceriskinpersonswithelevatedLDL-CExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.ATPIII:LDL-C,HDL-C,TCClassificationExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.LDL-C(mg/dL)100Optimal100–129Above,nearoptimal130–159Borderlinehigh160–189High190VeryhighHDL-C(mg/dL)40Low60HighTC(mg/dL)200Desirable200–239Borderlinehigh240HighATPIII:MajorCHDRiskFactorsOtherThanLDL-C•Cigarettesmoking•Hypertension:BP140/90mmHgoronantihypertensivemedication•LowHDL-C:40mg/dL*•FamilyhistoryofprematureCHD(1st-degreerelative):–malerelativeage55years–femalerelativeage65years•Age–male45years–female55years*HDL-C60mg/dLisanegativeriskfactorandnegatesoneotherriskfactor.ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.ATPIII:AdditionalCHDRiskFactorsExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults.JAMA.2001;285:2486-2497.•Life-habitriskfactors:targetsforintervention;notusedtosetlowerLDL-Cgoal–obesity–physicalinactivity–atherogenicdiet•Emergingriskfactors:canhelpguideintensityofrisk-reductiontherapy;donotcategoricallyalterLDL-Cgoals–lipoprotein(a)–homocysteine–impairedfastingglucose–prothromboticand–subclinicalatheroscleroticproinflammatoryfactorsdiseaseATPIII:AssessmentofRiskForpersonswithoutknownCHD,otherformsofatheroscleroticdisease,ordiabetes:•Countthenumberofriskfactors.•UseFraminghamscoringforpersonswith2riskfactors*todeterminetheabsolute10-yearCHDrisk.*Forpersonswith0–1riskfactor,Framinghamcalculationsarenotnecessary.ExpertPanelo