循证医学与内科临床实践.ppt

* Five major morbidity and mortality statin studies in primary or secondary prevention populations have been completed. This pyramid ranks the studies according to the type of patients that were included in each study. It begins with AFCAPS/TexCAPS, a primary prevention study in patients at low risk of CHD and moves to a smaller group of high-risk CHD patients in 4S, a secondary prevention study. In between the two extremes, covering the majority of patients with and at risk of CHD, are WOS, CARE, and LIPID. The Cholesterol and Recurrent Events (CARE) and Long-Term Intervention With Pravastatin in Ischaemic Disease (LIPID) studies are representative of the majority of patients with CHD, because patients in these trials had cholesterol levels that were, in general, considered to be in the average range (similar to those of the general population) rather than elevated.  * * 循证医学与心血管 临床实践 * Cardiac Arrhythmia Suppression Trial (CAST) 研究背景：心肌梗塞后心律失常是最主要致死原因，IC类抗心律失常药物副作用轻，被认为是最有前途的抗心律失常药。CAST企图通过用I-C类药物降低心肌梗塞病人的死亡率 设计：北美和欧洲27个中心100家医院中进行的随机双盲使用encainide，flecainide，moricizine 和安慰剂对照。共入选3549 AMI并有左室功能不全病人 随访：总成活率、无心脏事件和心律失常成活率 * 主要结果（提前终止） 一年后： 成活率 p值 对照组：95% 治疗组：90% 0.0006 一年后 无心律失常 p值 对照组： 96% 治疗组： 93% 0.003 结论: 用Ic类药物抑制心律失常不能改善心肌梗塞后的生成率, 相反增加死亡（2.5倍) 本研究说明，不能以推论代替实践 * 临床研究推动NCEP 指南的进展 1970s 1988 1993 2001 ATP I ATP II ATP III Framingham MRFIT LRC-CPPT 冠脉药物研究 赫尔辛基 心脏研究 CLAS (angio) 血管造影试验 (FATS, POSCH, SCOR, STARS, Ornish, MARS) 荟萃分析 (Holme, Rossouw) 4S, WOSCOPS, CARE, LIPID, AFCAPS/TexCAPS, VA-HIT, 其他 冠心病： LDL-C?2.6mmol/L 冠心病和 冠心病等危症： LDL-C2.6mmol/L HPS, ASCOT PROSPER ALLHAT TNT,IDEAL,SEARCH PROVE-IT ? ? * 二级预防观念的转变 心梗后的病人 冠心病 动脉粥样硬化疾病 糖尿病 多重危险因素，10年心血管事件危险〉20% * 危险评估的转变 Pre-ATP III Post-ATP III “一级预防” “二级预防” “计算危险因素” “相对危险下降” “全面危险因素评估 （低、中、高）” “ 冠心病等危症” “绝对危险下降” “代谢综合征” * ATPIII建议:降低LDL胆固醇为首要目标 LDL-C2.6mmol/L(100mg/dL) 冠心病和冠心病等危症 采取一致性的降胆固醇策略 JAMA 2001;285:2486-2497 * NCEP指南推荐的药物治疗的变化 Adapted from