Statin trong phòng ngừa biến cố động mạch vành PGS trương quang bình

DEMA-CVN.COM
GIỚI THIỆU
GIỚI THIỆU CÁC ĐỀ TÀI NGHIÊN CỨU KHOA
HỌC TẠI HỘI NGHỊ NỘI KHOA TOÀN
QUỐC TẠI THÀNH PHỐ HỒ CHÍ MINH
THÁNG 7/ 2011

DEMA-CVN.COM


Statin trong phòng ngừa
biến cố động mạch vành
PGS.TS Tröông Quang Bình
ĐHYD TP HCM

DEMA-CVN.COM


Gánh nặng tòan cầu của bệnh lý tim mạch
Năm 2002:
Tử vong do bệnh tim mạch chiếm 1/3 số tử vong toàn
cầu (17 triệu)
80% gánh nặng này sẽ đè trên vai của các quốc gia
có thu nhập thấp đến trung bình
Dự tính vào năm 2020:
Bệnh ĐM vành và đột q :nguyên nhân gây tử vong
và thương tật hàng đầu trên toàn thế giới
Tử vong do bệnh tim mạch sẽ tăng đến 20 triệu

=> Chăm sóc y tế cho bệnh tim mạch rất hao tốn
DEMA-CVN.COM

International Cardiovascular Disease Statistics 2005; AHA


Risk Factors for Atherothrombosis

Hypercoagulable states Life-style (e.g., Homocysteinaemia
smoking, diet,
Hyperlipidaemia
lack of exercise) Insulin resistance
Diabetes

Infection?

Obesity

Age

Hypertension
Genetics

Atherosclerosis
Gender

Atherothrombotic Manifestations
(MI, Ischemic Stroke, Vascular Death)

American Heart Association. Heart and Stroke Facts: 1997 Statistical Supplement; Wolf. Stroke 1990;21(suppl 2):II4–II-6; Laurila et al. Arterioscler Thromb Vasc Biol 1997;17:2910-2913; Grau et al. Stroke 1997;28:1724-1729;
DEMA-CVN.COM
Graham et al. JAMA 1997;277:1775-1781; Brigden.

Postgrad Med 1997;101(5):249-262.


Cholesterol and atherosclerosis
 LDL-C is strongly associated with an increased risk
of atherosclerosis and CVD events
 HDL-C has a protective effect for the risk of
atherosclerosis and CHD.
1% decrease in LDL-C
reduces CHD risk by 1%1

1.Grundy SM et al. Circulation. 2004; 110: 227–39.
2.Gordon DJ, Probstfield JL, Garrison JD et al. Circulation 1989; 79: 8-15.
3.Boden W. American Journal of Cardiology 2000; 86 (suppl): 19L-22L.
4.Manninen V, Elo O, Frick MH et al. JAMA 1988; 260:641-651.
5.Rubins HB, Robins S, Collins D et al. N Engl J Med 1999; 341:410-418

1% change in HDL-C
associated with 1-3%
reduction in CHD risk2-5


Key Statin Trials and
Spectrum of Risk
CHD/high cholesterol
4S
CHD/average to high cholesterol
LIPID
CHD/low to average cholesterol
PROVE-IT

MI/low to average cholesterol
CARE
Increasing
MI/low to average cholesterol
IDEAL
absolute CHD
CHD or diabetes/low to average cholesterol
HPS
risk
TNT
CHD/low to average cholesterol
CARDS
Diabetes + 1 other risk factor/low to average cholesterol
PROSPER
CHD or risk factors/average cholesterol
WOSCOPS
no MI/high cholesterol
ALLHAT-LLT
some CHD/average cholesterol
ASCOT-LLA
>3 risk factors/low to average cholesterol
AFCAPS/TexCAPS
No CHD/average cholesterol
JUPITER
No CHD/low to normal cholesterol
DEMA-CVN.COM


Nghiên cứu 4S: mở đường cho ATP III
 Trước NC 4S, statin:

* Giảm tử vong do bệnh ĐMV, chưa giảm tử vong chung.
 NC 4S (Scandinavian Simvastatin Survival Study), 1994:

* Giảm tử vong do bệnh ĐMV và tử vong chung 30%.
 NC 4S là NC đầu tiên trả lời chính thức về tác dụng có lợi của

statin trong điều trò RLLP máu.

 NC 4S có ảnh hưởng lớn cho khuyến cáo ATP III
7


HPS = Heart Protection Study


NC tiền cứu, ngẫu nhiên, so sánh chéo (simvastatin với
giả dược).

 Mục tiêu NC: Simvastatin có làm giảm tỷ lệ tử vong và

các biến cố tim mạch cho đối tượng có nguy cơ cao.

 Tiêu chí chính: Tỷ lệ tử vong chung, Tỷ lệ các biến cố

tim – mạch gây tử vong và không gây tử vong.

 Thời gian theo dõi trung bình : 5 năm

8

Heart Protection Study
(Nghiên cứu kéo dài 5 năm)

Simvastatin
40 mg
Nguy cơ
BMV

Giảm 26% nguy cơ
BMV

Simvastatin
40 mg

Giảm 22% nguy cơ BMV

60

100

LDL-C (mg/dL)

Heart Protection Study Collaborative Group. Lancet 2002;360:7–22.

9


TNT Trial

10,003 bệnh nhân bệnh ĐM vành ổn đònh
Tuổi 35-75 , LDL từ 130 - 250 mg/dL, triglyceride ≤ 600 mg/dL
19% là nữ, tuổi trung bình 60.3
Tất cả được dùng atorvastatin 10 mg trong 8 tuần đầu

Atorvastatin 80 mg
n=4,995

Atorvastatin 10 mg
n=5,006

Primary Endpoint: Biến cố tim mạch chính : tử vong do bệnh
ĐM vành ,NMCT không tử vong, ngưng tim được hồi sức, đột q
gây tử vong hoặc không tử vong . Theo dõi 4.9 năm.

DEMA-CVN.COM


TNT Trial: Primary endpoint
Primary Composite of CHD death, nonfatal MI, resuscitated
cardiac arrest, and fatal or nonfatal stroke
Hazard Ratio [HR]=0.78
p<0.001

DEMA-CVN.COM


IDEAL (Incremental Decrease in End Points
Through Aggressive Lipid Lowering)
 8888 patients, 80 years or less with prior MI

randomised to atorvastatin 80 mg/d (n = 4439), or
simvastatin 20 mg/d (n = 4449), with a median
follow-up of 4.8 years.

 Primary endpoint was occurrence of a major

coronary event (coronary death, confirmed nonfatal
acute MI, or cardiac arrest with resuscitation).

12


IDEAL
 Major coronary event in 463 on simvastatin (10.4%) and

411 on atorvastatin (9.3%) P = 0.07 (not significant);
nonfatal MI in 321 (7.2%) and 267 (6.0%) (P = 0.02).

 No differences in cardiovascular or all-cause mortality.
 Patients with MI may benefit from intensive lowering of

LDL-C without an increase in noncardiovascular mortality
or other serious adverse reactions.

13


PROVE-IT
The Pravastatin or Atorvastatin Evaluation and

Infection Therapy trial (PROVE-IT/TIMI-22)
 4162 Patients with acute coronary syndrome

within the preceeding 10 days.

 Aggressive lipid-lowering using atorvastatin 80

mg/day versus using pravastatin 40 mg/day.

14


PROVE-IT likely benefits
 Atorvastatin 80 mg: additional 18%

reduction in nonfatal MI and CHD death
beyond treatment with pravastatin 40 mg.

 Extrapolation of the event rate:

approximate additional 22% reduction in
major CHD events in the atorvastatin
group at 5 years.

15


On-Treatment LDL-C is Closely Related to
CHD Events in Statin Trials
30

4S - Pl

25

Secondary Prevention

Rx - Statin therapy
Pl – Placebo
Pra – pravastatin
Atv - atorvastatin

4S - Rx

20

LIPID - Pl
15
CARE - Pl

LIPID - Rx
CARE - Rx
HPS - Rx

10

TNT – Atv80

TNT – Atv10
PROVE-IT - Pra

HPS - Pl

PROVE-IT – Atv
5

0
40
(1.0)

60
(1.6)

80
(2.1)

100
(2.6)

120
(3.1)

140
(3.6)

160
(4.1)

180
(4.7)

200
(5.2)

LDL-C achieved mg/dL (mmol/L)
DEMA-CVN.COM
Rosenson RS. Exp Opin Emerg Drugs 2004;9(2):269-279, LaRosa JC et al. N Engl J Med 2005;352:1425-1435.


MCAEs (30 days)

MCAEs (%)

P=0.002

18

15.9

16
14
12
10
8

6.7

6
4

2
0

Rosuvastatin
DEMA-CVN.COM

Control


DEMA-CVN.COM


Why Is LIPS Unique?
• In previous secondary prevention trials
– PCI in subpopulations only
– multiple previous PCIs allowed
– PCI in distant past allowed
• LIPS is the first prospective secondary
prevention statin trial with cardiac outcomes
(time to first MACE) as the primary endpoint to
exclusively study the post-PCI population

PCI, percutaneous coronary intervention; MACE, major adverse cardiac event.


Primary Endpoint:
MACE-Free Survival Time
100

Subjects

free from
MACEs
(%)

90

Risk reduction = 22%
Fluvastatin

P=0.0127

80
Placebo
70
0
0.0

0.5

Subjects at risk (% survival)
Fluvastatin
Placebo

844 (100.0)
833 (100.0)

1.0
1.5
2.0
2.5

3.0
Years post randomization
703 (84.2)
686 (83.6)

666 (80.9)
642 (78.8)

647 (80.2)
610 (76.1)

3.5

4.0

250 (78.3)
228 (72.6)

MACE, major adverse cardiac event.
Serruys PW. Presented at: ACC 51st Annual Scientific Session;
March 20, 2002; Atlanta, GA.


A large number of clinical events occur in those
with below average cholesterol levels
Total Cholesterol Distribution: CHD vs Non-CHD Population
Framingham Heart Study—26-Year Follow-up
No CHD

35% of CHD Occurs

in People with
TC<5.0 mmol/L

4

CHD

5

6.5

7.7

Total Cholesterol (mmol/L)
Castelli WP. Atherosclerosis. 1996;124(suppl):S1-S9.
DEMA-CVN.COM
1996 Reprinted with permission from Elsevier Science.


Key statin trials on
Primary prevention studies
WOSCOPS
(1995)
AFCAPS/TexCAPS (1998)
ALLHAT-LLA
(2002)
ASCOT-LLA
(2003)
JUPITER
(2008)

DEMA-CVN.COM


Cardiovascular Endpoints: WOSCOPS

Subjects with No Previous MI but Raised Cholesterol
Number of events
Outcomes

Nonfatal MI/CHD
death*
CHD death
Nonfatal MI
PCTA/CABG
Stroke
All cardiovascular
deaths
Total mortality#

placebo
(n=3293)

pravastatin
(n=3302)

RRR
(%)

p-value

248

174

31

<0.001

52
204
80
51
73

38
143
51
46
50

28
31
37
11
32

ns
<0.001
0.009
ns

0.033

135

106

22

0.051

* primary endpoint
# study not powered to detect differences in this endpoint
RRR relative risk reduction
Shepherd J et al. N Engl J Med 1995;333:1301–1307.


Nonfatal MI and CHD Death: WOSCOPS
12

placebo (n=3293)
pravastatin (n=3302)

10
8
6

31%
relative
risk
reduction

p<0.001

4
2
0
1

2

3

4

5

6

Years

Shepherd J et al. N Engl J Med 1995;333:1301–1307.


AFCAPS/TexCAPS
– 6605 patients.
– Average TC and LDL-C levels (Mean TC 5.71
mmol/L, LDL-C 3.89 mmol/L, mean HDL-C level 0.94 mmol/L and
median (SD) TG levels were 1.78 (0.86) mmol/L).

– Without clinically evident atherosclerotic
cardiovascular disease

DEMA-CVN.COM