美国哈佛医学院Marc S Sabatine团队研究了降低老年患者低密度脂蛋白胆固醇的疗效与安全性。2020年11月10日，该研究发表在《柳叶刀》杂志上。

降低低密度脂蛋白（LDL）胆固醇来治疗老年患者的临床疗效仍在争论。为了总结老年患者LDL胆固醇降低治疗的效果，研究组检索了MEDLINE和Embase数据库在2015年3月1日至2020年8月14日期间发表的文章，并进行系统回顾和荟萃分析。纳入2018年美国心脏病学会和美国心脏协会指南推荐的一种LDL胆固醇降低药物心血管结局的随机对照试验，平均随访时间至少为2年，并收集老年患者（年龄≥75岁）的数据。

研究组共确定了6篇文章，其中包括24项胆固醇治疗试验专家合作的荟萃分析和5项个体试验。29项临床试验的244090例患者中，年龄≥75岁的有21 492例（8.8%），其中11750例（54.7%）来自他汀类试验，6209例（28.9%）来自依泽替米贝试验，3533例（16.4%）来自PCSK9抑制剂试验。

中位随访时间为2.2-6.0年。降低LDL胆固醇可显著降低老年患者发生重大心血管事件的风险，LDL胆固醇每降低1 mmol/L，风险降低26%（减少3519人），但与75岁以下患者的风险降低无统计学意义。在老年患者中，他汀类药物和非他汀类药物的风险比无统计学差异。老年人降低LDL胆固醇获益较多，其中心血管死亡的风险比为0.85，心肌梗死为0.80，中风为0.73，冠状动脉血运重建为0.80。

研究结果表明，对于75岁以上的患者中，降脂可显著减少心血管事件。

附：英文原文

Title: Efficacy and safety of lowering LDL cholesterol in older patients: a systematic review and meta-analysis of randomised controlled trials

Author: Baris Gencer, Nicholas A Marston, KyungAh Im, Christopher P Cannon, Peter Sever, Anthony Keech, Eugene Braunwald, Robert P Giugliano, Marc S Sabatine

Issue&Volume: 2020-11-10

Abstract:

Background

The clinical benefit of LDL cholesterol lowering treatment in older patients remains debated. We aimed to summarise the evidence of LDL cholesterol lowering therapies in older patients.

Methods

In this systematic review and meta-analysis, we searched MEDLINE and Embase for articles published between March 1, 2015, and Aug 14, 2020, without any language restrictions. We included randomised controlled trials of cardiovascular outcomes of an LDL cholesterol-lowering drug recommended by the 2018 American College of Cardiology and American Heart Association guidelines, with a median follow-up of at least 2 years and data on older patients (aged ≥75 years). We excluded trials that exclusively enrolled participants with heart failure or on dialysis because guidelines do not recommend lipid-lowering therapy in such patients who do not have another indication. We extracted data for older patients using a standardised data form for aggregated study-level data. We meta-analysed the risk ratio (RR) for major vascular events (a composite of cardiovascular death, myocardial infarction or other acute coronary syndrome, stroke, or coronary revascularisation) per 1 mmol/L reduction in LDL cholesterol.

Findings

Data from six articles were included in the systematic review and meta-analysis, which included 24 trials from the Cholesterol Treatment Trialists' Collaboration meta-analysis plus five individual trials. Among 244090 patients from 29 trials, 21492 (8·8%) were aged at least 75 years, of whom 11750 (54·7%) were from statin trials, 6209 (28·9%) from ezetimibe trials, and 3533 (16·4%) from PCSK9 inhibitor trials. Median follow-up ranged from 2·2 years to 6·0 years. LDL cholesterol lowering significantly reduced the risk of major vascular events (n=3519) in older patients by 26% per 1 mmol/L reduction in LDL cholesterol (RR 0·74 [95% CI 0·61–0·89]; p=0·0019), with no statistically significant difference with the risk reduction in patients younger than 75 years (0·85 [0·78–0·92]; p interaction=0·37). Among older patients, RRs were not statistically different for statin (0·82 [0·73–0·91]) and non-statin treatment (0·67 [0·47–0·95]; p interaction=0·64). The benefit of LDL cholesterol lowering in older patients was observed for each component of the composite, including cardiovascular death (0·85 [0·74–0·98]), myocardial infarction (0·80 [0·71–0·90]), stroke (0·73 [0·61–0·87]), and coronary revascularisation (0·80 [0·66–0·96]).

Interpretation

In patients aged 75 years and older, lipid lowering was as effective in reducing cardiovascular events as it was in patients younger than 75 years. These results should strengthen guideline recommendations for the use of lipid-lowering therapies, including non-statin treatment, in older patients.

DOI: 10.1016/S0140-6736(20)32332-1

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32332-1/fulltext