自然降血脂 – 助您减少对药物的依赖！
我们要不要降血脂，前面两篇文章让读者有疑惑。您看Christopher P. Cannon医生（哈佛大学医学院附属布列根和妇女医院）（也是JAMA 美国医学会杂志的编委）是最为激进的降血脂派，他的观点是'lower isbetter（越低越好）’。但是笔者在这里给大家传递一个观点，现代医学之父威廉奥斯勒这样描述医学，'一门不确定科学和可能性的艺术。’ 所以我们还是要建议有心血管疾病风险的患者控制胆固醇水平，但是自然降血脂减少对药物的依赖是最好的方法。
这里给出六条自然降血脂的小提示，供大家参考：
多吃含有单一不饱和脂肪酸的食物。很多控脂饮食方案虽然会降低体重，减少血液中所谓有害的胆固醇（LDL），但是也会减少血液中所谓有益的胆固醇（HDL）。但是富含单一不饱和脂肪酸的食物就只减少LDL，不减少HDL。这类食物有，橄榄和橄榄油、菜籽油、坚果类食物（杏仁、花生、山核桃、榛子、腰果等）、牛油果
多食用富含多不饱和脂肪酸的食物，特别是富含Omega-3s的食物。例如，三文鱼、马鲛鱼、鲱鱼、还有深海鱼类比如金枪鱼，以及植物的种子（不包括花生）等
多吃可溶性纤维。这类食物包括豆类食物、各种水果、燕麦和全麦等等
在物理治疗师和健康教练的指导下科学锻炼与减肥。
不要吸烟，控制饮酒等等。
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专业同行继续往下看。
首先建议大家看一下Peter Lin医生对于最新的2018胆固醇指南的总结，Peter是加拿大心脏研究中心，全科医学项目总监。他这篇对指南的总结强调了对患者心血管风险评估的重要性，因为只有在正确评估的基础上才能决定用药的程度与指导患者减少对药物依赖的方案。
Cholesterol Guidelines 2018: Quick Summary
This article provides the highlights of thefirst lipid guideline update since 2013. That 2013 guideline created hugedebates because there was a deemphasis on LDL-C targets and statin was the mainrecommended therapy. This was because, up to 2013, the studies that showed CVbenefits were mainly statin trials. Also, these studies were not target-driven;they just gave the dose of statin and wherever the LDL-C ended was where itended. So, the 2013 guidelines followed what was done in the trials andrecommended statins of the same intensity that were used in the trials asopposed to specific LDL-C targets.
Now in the last few years, the PCSK9inhibitor trials have come out and, in the very high risk ASCVD population, theaddition of a PCSK9 inhibitor did reduce CV events beyond statins alone.Therefore, we can add them to statins. Also, ezetimibe showed some modestbenefits on top of simvastatin as well. Hence, this new guideline deals withwhen we should be thinking of adding on these medications while alwaysremembering that the cost could be significant.
The guidelines start off by looking at therisks and the benefits. So first, we assess the risk of the patient then decidehow much treatment is needed. As before, there are patients at such high riskthat you don’t need a risk calculation. They all need treatment withhigh-intensity statin. The goal is at least 50% reduction in LDL-C.
The “very high risk ASCVD” patients whoseLDL-C levels are still more than 70 mg/dL are like the patients in the PCSK9inhibitor trials. If, despite high-dose statins, their LDL-C is still above 70mg/dL, we can add ezetimibe and thereafter we can consider a PCSK9 inhibitor.The ezetimibe was not a requirement in the PCSK9 inhibitor trials; but, foreconomic purposes, it should be considered before a PCSK9 inhibitor.
The definition of a “very high risk ASCVD”patient is someone with multiple ASCVD events or with just one ASCVD event butadditional risk factors (age >65 years, diabetes, hypertension, chronickidney disease, heart failure, smoking, prior CABG/PCI, or persistent LDL-C>100 mg/dL). In other words, a 65-year-old with an MI or a diabetes patientwith an MI would be considered very high risk. So, these are not patients whoonly specialists see. They are very much in our primary care offices.
The next category in the guidelines are thepatients with LDL-C >190 mg/dL. This captures the familiarhypercholesterolemia patients and they, too, can be treated without doing arisk calculation. The target is at least 50% reduction in LDL-C, and the LDL-Cshould be <100 mg/dL.
Also, the risk is high enough in patientswith only diabetes that they do not need a risk calculation and they should betreated with statin therapy; however, the diabetes trials only usedmoderate-intensity statin dosing. Therefore, the recommendation is to usemoderate-intensity statins with at least a 30% LDL-C reduction. This seems tobe undertreatment of a high-risk population, but that is what happens when youhave to follow trials to a “T.” Sometimes we are trapped by “evidence-basedmedicine” because we can only recommend what has been proven.
Finally, for patients who do not haveASCVD, LDL-C >190 mg/dL, or diabetes, then we do need to use the CV riskcalculator. The new ranges for 10-year risks are as follows: 1) low risk,<5%; 2) borderline risk, 5 to 7.4%; 3) intermediate risk, 7.5% to 19.9%; and4) high risk, >20%. The two extremes are simple to remember. For high-riskpatients, treat them like ASCVD patients, which means high-intensity statintherapy and at least a 50% reduction in LDL-C. Low-risk patients don’t needtreatment. Intermediate risk is always the grey area. However, HOPE-3 was astudy that looked at the intermediate-risk patient, and rosuvastatin 10 mg didreduce CV events. Hence, most intermediate-risk patients should be treated.Now, for borderline risk patients, we need to look at other high-risk features,including family history of ASCVD, metabolic syndrome, and CKD. A calcium scoremay be useful, but usually reserved for those uncertain cases, which arehopefully few in number.
This guideline has nicely incorporated theevidence from the new trials and has given good guidance on when we should bethinking of statin therapy and when we should be thinking about the addition ofezetimibe or PCSK9 inhibitors. Hopefully this will help us get the righttherapy for the right patient—in a sense, this embodies the concept ofpersonalized medicine.
资料来源：Grundy SM, Stone NJ, Bailey AL, et al.2018 AHA/ ACC/ AACVPR/ AAPA/ ABC/ ACPM/ ADA/ AGS/ APhA/ ASPC/ NLA/ PCNAguideline on the management of blood cholesterol: a report of the AmericanCollege of Cardiology/American Heart Association Task Force on ClinicalPractice Guidelines. J Am Coll Cardiol. 2018 Nov 8. doi:10.1016/j.jacc.2018.11.003. [Epub ahead of print.]https://www.sciencedirect.com/science/article/pii/S073510971839034X