目的:临床综合网络的质量和护理模式委员会要求对南卡罗来纳州患者人群实施2013年和2014年胆固醇指南的预期心血管益处进行比较分析。第二个要求是根据文献评估两个指南的相对风险。
方法:从2013年1月至2015年6月进行了一次或多次访问的1,580,860名21-80岁成年人的电子健康数据;566,688名数据用于计算10年动脉粥样硬化性心血管疾病(ASCVD10)风险。患有终末期肾病的成年人(n=7852),充血性心力衰竭(n=19,818),酒精或药物滥用(n=68,547),或目前使用他汀类药物(n=154,964)被排除,留下315,508进行分析。ASCVD10的估计减少假设:(a)中等强度他汀类药物使低密度脂蛋白胆固醇(LDL-C)降低了35%,高强度他汀类药物降低了50%;(b)LDL-C每降低1mmol/l,ASCVD事件下降了22%。
结果:在分析的315,508名成年人中,根据2013年指南,有131,289(41.6%)符合他汀类药物的资格,根据2014年指南,有137,375(43.5%)符合他汀类药物的资格。估计2013年和2014年指南可在10年内预防6780和5915例ASCVD事件,其中:(a)相对风险降低29.0%和21.8%;(b)绝对风险降低5.2%和4.3%;(c)需要治疗的数量(NNT)分别为19和23。根据2013年指南,更高的心血管保护计划在很大程度上与更多地使用高剂量他汀类药物有关。不良事件的风险更大。文献表明,在高风险患者中,高强度与中等强度他汀类药物的获益NNT为31,需要伤害的人数为47。
结论:2013年指南预计将预防更多的临床ASCVD事件,并且NNTs低于2014年指南,但两者都有很大的好处。2013年指南还预计会产生更多的不良事件,但是风险-收益状况似乎很有利。
OBJECTIVE: The Quality and Care Model Committee for a clinically integrated network requested a comparative analysis on the projected cardiovascular benefits of implementing either the 2013 and 2014 cholesterol
guideline in a South Carolina patient population. A secondary request was to assess the relative risk of the two
guidelines based on the literature.
METHODS: Electronic health data were obtained on 1,580,860 adults aged 21-80 years who had had one or more visits from January 2013 to June 2015; 566,688 had data to calculate 10-year atherosclerotic cardiovascular disease (ASCVD10) risk. Adults with end-stage renal disease (n = 7852), congestive heart failure (n = 19,818), alcohol or drug abuse (n = 68,547), or currently on statins (n = 154,964) were excluded leaving 315,508 for analysis. Estimated reduction in ASCVD10 assumed that: (a) moderate-intensity statins lowered low-density lipoprotein cholesterol (LDL-C) by 35% and high-intensity statins by 50%; (b) ASCVD events declined 22% for each 1 mmol/l fall in LDL-C.
RESULTS: Among the 315,508 adults in the analysis, 131,289 (41.6%) were eligible for statins according to the 2013 guideline and 137,375 (43.5%) to the 2014
guideline. The 2013 and 2014
guidelines were estimated to prevent 6780 and 5915 ASCVD events over 10 years with: (a) relative risk reductions of 29.0% and 21.8%; (b) absolute risk reductions of 5.2% and 4.3%; (c) number needed-to-treat (NNT) of 19 and 23, respectively. The greater projected cardiovascular protection with the 2013 guideline was largely related to greater use of high-dose statins, which carry a greater risk for adverse events. The literature indicates that the NNT for benefit with high-intensity versus moderate-intensity statins is 31 in high-risk patients with a number needed-to-harm of 47.
CONCLUSIONS: The 2013 guideline is projected to prevent more clinical ASCVD events and with lower NNTs than the 2014
guideline, yet both have substantial benefit. The 2013 guideline is also expected to generate more adverse events, but the risk-benefit profile appears favor .