冠心症血脂控制新策略：低密度脂蛋白膽固醇是否愈低愈好？

The Management of Low-density Lipoprotein in Cardiovascular disease- The Lower the Better?

鄭朝允(Chao-Yun Cheng) ； 趙庭興(Ting-Hsing Chao)

《內科學誌》 33卷2期 (2022/04) Pp. 81-90

https://doi.org/10.6314/JIMT.202204_33(2).01

摘要

動脈粥狀硬化的形成與低密度脂蛋白膽固醇高低有密切的關係，使用降血脂藥物，例如：他汀類藥物、非他汀類藥物（如ezetimibe）以及前蛋白轉化酶枯草溶菌素9（proprotein convertase subtilisin/kexin type 9, PCSK9）抑制劑等，可以有效改善低密度脂蛋白膽固醇濃度，達到理想的治療目標。至於何謂理想的目標值，根據過去文獻報告，不論在初級預防或者是次級預防，愈低的低密度脂蛋白膽固醇，通常帶來更好心血管的預後。特別是亞洲族群，平均低密度脂蛋白膽固醇濃度較西方人為低，加上對於他汀類藥物有較佳反應，針對亞洲族群所做的他汀類研究似乎有超乎預期的心血管保護效應。就安全性而言，薈萃分析研究指出，較低的低密度脂蛋白膽固醇並沒有導致比安慰劑組更多的不良反應。過去僅少數幾篇文獻指出，使用較高劑量的他汀藥物，也許會增加肝功能指數上升、肌肉相關問題以及新診斷糖尿病等風險。針對非常高危險的冠心症族群，依據回溯性分析，將低密度脂蛋白膽固醇的數值控制介於30到55 mg/dL之間，不論在效度以及安全性上，或許可以達到最平衡最理想的效果。

關鍵字

冠狀動脈疾病（Coronary artery disease） ； 急性冠心症（Acute coronary syndrome） ； 低密度脂蛋白膽固醇（Low density lipoprotein cholesterol）

並列摘要

A robust evidence supports the association of the incidence of atherosclerotic disease and the level of low-density lipoprotein cholesterol (LDL-C). With the help of optimal outcome-proven lipid-lowering treatment, such as statins, ezetimibe or proprotein convertase subtilisin/kexin type 9 (PCSK 9) inhibitors, the goal attainment rate of LDL-C is improving in patients with cardiovascular (CV) disease. Lots of studies showed better cardiovascular outcomes while achieving lower LDL-C levels either in primary or secondary prevention. However, some adverse effects, including liver and muscular complications, new onset diabetes mellitus or neurocognition disorders, with potent statin treatment to achieve lower LDL-C levels should be kept in mind. Nevertheless, these side effects were not observed in other lipid-lowering treatment, such as ezetimibe or PCSK9 inhibitors, even when very low LDL-C levels were achieved. According to this evidence-based review, the ideal LDL-C level with optimal CV benefit, minimal adverse effect, and favorable cost-effectiveness could be around 30 to 55 mg/dL, especially in patients at high CV risk.