2023+中国指南：血脂管理（英文）.pdf

2023 China Guidelines for Lipid ManagementJian-JunLI1,Shui-PingZHAO2,DongZHAO3,Guo-PingLU4,Dao-QuanPENG2,JingLIU3,Zhen-YueCHEN4,Yuan-LinGUO1,Na-QiongWU1,Sheng-KaiYAN5,Zeng-WuWANG1,Run-LinGAO1,;on behalf of Joint Committee on the 2023 China Guidelines forLipid Management1.National Center for Cardiovascular Diseases,Fuwai Hospital,Chinese Academy of Medical Sciences,Beijing,China;2.The Second Xiangya Hospital of Central South University,Changsha,Hunan,China;3.Beijing Anzhen Hospital,Cap-ital Medical University,Beijing,China;4.Ruijin Hospital,Shanghai Jiaotong University School of Medicine,Shanghai,China;5.Affiliated Hospital of Zunyi Medical University,School of Laboratory Medicine of Zunyi Medical University,Zunyi,Guizhou,ChinaCorrespondence to:(LI JJ);(ZHAO SP);(GAO RL)https:/doi.org/10.26599/1671-5411.2023.09.008ABSTRACTAtherosclerotic cardiovascular disease(ASCVD)is the leading cause of death among urban and rural residentsin China,and elevated low-density lipoprotein cholesterol(LDL-C)is a risk factor for ASCVD.Considering the increasing bur-den of ASCVD,lipid management is of the utmost importance.In recent years,research on blood lipids has made breakthroughsaround the world,hence a revision of China guidelines for lipid management is imperative,especially since the target lipid levelsin the general population vary in respect to the risk of ASCVD.The level of LDL-C,which can be regarded as appropriate in apopulation without frisk factors,can be considered abnormal in people at high risk of developing ASCVD.As a result,the“Guidelines for the prevention and treatment of dyslipidemia”were adapted into the“China Guidelines for Lipid Management”(henceforth referred to as the new guidelines)by an Experts committee after careful deliberation.The new guidelines still recom-mend LDL-C as the primary target for lipid control,with CVD risk stratification to determine its target value.These guidelines re-commend that moderate intensity statin therapy in adjunct with a heart-healthy lifestyle,be used as an initial line of treatment,followed by cholesterol absorption inhibitors or/and proprotein convertase subtilisin/kexin type 9(PCSK9)inhibitors,as neces-sary.The new guidelines provide guidance for lipid management across various age groups,from children to the elderly.Theaim of these guidelines is to comprehensively improve the management of lipids and promote the prevention and treatment ofASCVD by guiding clinical practice.Cardiovascular disease(CVD)is the mostcommon chronic non-communicable dis-ease threatening human life and healthglobally.CVD,and especially atherosclerotic cardi-ovascular disease(ASCVD)(e.g.,ischemic heart dis-ease and ischemic stroke),is the leading cause ofdeath among urban and rural residents in China,acc-ounting for more than 40%of the deaths.1 CVD refersto a class of diseases that affect the heart and bloodvessels.It encompasses various conditions such ascoronary artery disease,heart failure,arrhythmias,valvular heart diseases,and peripheral artery dis-ease.The component events of CVD can vary de-pending on the specific condition but may includecoronary artery blockage,heart attack,heart failure,arrhythmias(abnormal heart rhythms),and prob-lems with heart valves or the blood vessels.Athero-sclerotic Cardiovascular Disease(ASCVD):ASCVDspecifically refers to a subset of cardiovascular dis-eases caused by the buildup of plaque in the arter-ies,leading to atherosclerosis.ASCVD primarily in-volves conditions like coronary artery disease,cerebrovascular disease(stroke),and peripheralartery disease.The primary component events ofASCVD are related to the development and con-sequences of plaque buildup in the arteries.Theseinclude coronary artery blockage leading to anginaor heart attack,carotid artery disease resulting instroke,and peripheral artery disease leading to re-duced blood flow to the extremities.In recent years,the disease burden of ASCVD in China has contin-ued to increase,2 and the situation of preventionand control is severe.Hence,there is an urgent needto improve the measures of prevention and treatmentof ASCVD.There is strong evidence from epidemiological,Journal ofGeriatric CardiologyJournal ofGeriatric CardiologyJournal ofGeriatric CardiologyJournal ofGeriatric CardiologyJournal ofGeriatric CardiologyGUIDELINEJ Geriatr Cardiol 2023;20(9):6216632023 JGC All rights reserved;genetic,and clinical interventional studies confirm-ing that low-density lipoprotein cholesterol(LDL-C)is a risk factor for ASCVD.3 Recent studies alsosuggest that other apolipoprotein B(ApoB)contain-ing lipoproteins,including triglyceride-rich lipopro-teins(TRL)and their residues,as well as lipopro-tein(a)Lp(a),are not only involved in the patho-physiology of ASCVD but may also be associatedwith events such as atherosclerotic thrombosis.3The age-adjusted coronary heart disease mortal-ity rate in the United States in the 20th century showedthe start of a declining trend in 1968 and decreasedby more than 40%between 1980 and 2000.The con-tribution of controlling the risk factors accountedfor 44%,and the largest contributor was the reduc-tion of total cholesterol(TC)levels which accoun-ted for 24%.4 To the contrary,data show that theTC,LDL-C,and triglyceride(TG)levels of Chineseresidents have increased significantly in 2012 com-pared to 2002,while high-density lipoprotein cho-lesterol(HDL-C)decreased significantly,and theprevalence of dyslipidemia in people aged 18years has increased significantly.5 The awareness-,treatment-and control-rate of dyslipidemia amongresidents are at a low level during the same time periods.As a result,China is facing an increasing trend ofASCVD disease burden,and lipid management isurgent.In 2007,the Chinese Society of Cardiology,with thesupport of the former Center for Disease Controland Prevention of Ministry of Health of the PeoplesRepublic of China,organized a joint committee ofmultidisciplinary Experts to develop the China Gui-delines on Prevention and Treatment of Dyslipidemiain Adults6 based on the 1997 Recommendations forPrevention and Treatment of Dyslipidemia.7 In 2016,the National Experts Committee for Cardiovascu-lar Diseases of the National Center for Cardiovascu-lar Disease,in collaboration with the former Centerfor Disease Control and Prevention of National Hea-lth and Family Planning Commission of the PeoplesRepublic of China,organized a multidisciplinaryExpert committee.The objective of the committeewas to document the progress of national and inter-national research in the field of dyslipidemia,focus-ing on epidemiological and clinical research evid-ence in China,and comprehensively integrate itwith the international dyslipidemia guidelines,toformulate the 2016 China Guidelines for the Man-agement of Dyslipidemia in Adults.8 This guide-line put forward more suitable dyslipidemia man-agement recommendations for the Chinese popula-tion and was pivotal in guiding the prevention andtreatment of dyslipidemia,including at the grass-roots level.9Following the publication of the 2016 ChinaGuidelines for the Management of Dyslipidemia inAdults,the causal relationship between LDL-C andatherosclerosis was established.Research also dem-onstrated that the combination of lipid-lowering drugsand use of new drug classes such as proprotein con-vertase subtilisin/kexin type 9(PCSK9)inhibitorscan reduce LDL-C levels by 50%to 70%,resulting infurther reduction in major adverse cardiovascularevents(MACE)based on statin therapy.This obser-vation reaffirmed that additional substantial LDL-Creductions can lead to greater cardiovascular pro-tection.10,11 These new clinical trial results have ledto updates and revisions of many foreign lipid man-agement guidelines,12,13 which tend to emphasizemore stringent LDL-C control goals,especially forpatients at high risk for ASCVD.Additionally,sig-nificant progress has been made researching the re-sidual cardiovascular risk associated with lipids.Based on the above background,the National Cardio-vascular Disease Expert Committee,together withthe Chinese Society of Cardiology,the Chinese Soci-ety of Endocrinology,the Chinese Diabetes Society,the Chinese Society of Laboratory Medicine and theChinese Stroke Association,formed a joint Expertcommittee of multidisciplinary Experts to updatethe 2016 China Guidelines for the Management ofDyslipidemia in Adults.The aim of this committeewas to guide clinical practice to comprehensivelyimprove the level of lipid management in China bypromoting CVD prevention and treatment.Considering that the target levels of lipids in thepopulation varies with the level of ASCVD risk stra-tification,the LDL-C level,which can be regardedas“normal”in a population without risk factors,may be considered significantly“elevated”in pa-tients with ultra(very)high risk of ASCVD.There-fore,after careful and extensive deliberations,theExperts committee on guideline revision decided torevise the“Guidelines for the Management of Dys-lipidemia”to“Guidelines for Lipid Management”.JOURNAL OF GERIATRIC CARDIOLOGYGUIDELINE622http:/;In addition,as dyslipidemia and atherosclerosismay have onset in childhood,lipid managementshould also be initiated in children and youngadults.This guideline includes recommendationsfor lipid management in children as well as for pa-tients in various age groups.Therefore,the Expertscommittee unanimously agreed to rename thenewly revised guideline as 2023 China Guidelinesfor the Management of Blood Lipids.This guideline revision process followed themethodology and procedures as outlined by theWorld Health Organization and the Chinese Medic-al Association for guideline development/revision.8Firstly,the main contents and core issues of the newguideline were solicited from the Expert committeemembers,and a total of 15 core issues in 6 areas(1.general principles of guideline revision,2.main cont-ents of update,3.overall cardiovascular risk assess-ment,4.goals of lipid-lowering therapy,5.pharma-cological and non-pharmacological treatment meas-ures for lipid-lowering therapy,and 6.lipid man-agement in children and special populations)wereidentified after research and ranked.The guidelinerevision working group developed a literature searchand evaluation strategy based on the core issues.The results from the comprehensive search of Chineseand English literature databases were then providedto the Experts to conduct a systematic review and evalu-ation,paying special attention to the collection andadoption of results and data from national clinicalstudies and population-based cohort studies.Dur-ing the preparation process,the Experts committeeheld seven symposiums to discuss the core issues.Based upon the systematic literature review,the Ex-perts committee reached consensus after repeateddiscussion sessions,made recommendations,andassigned levels of evidence.In the instances wherethere was difference of opinion after repeated dis-cussions,the opinion supported by majority of theexperts was accepted.The definition of levels of recommendation classi-fications and levels of evidence in this guideline arebased on corresponding lipid management guidelinesfrom Europe and the United States.12,13The definitions of the recommended classifica-tions in this guide are expressed as follows:Class:treatments or operations for which thereis proven and/or consistent recognition of benefits,usefulness,or effectiveness are recommended.Class:treatments or operations for which theevidence of usefulness and/or effectiveness is stillcontradictory or for which there are different opin-ions.Class a:evidence,opinions that tend to be use-ful and/or effective,and the application of thesetreatments or operations is justified.Class b:the relevant evidence and views arenot yet adequate to prove useful and/or effective,but the application can be considered.Class:treatments or operations that have beenproven and/or unanimously recognized as ineffect-ive and may be unsafe in some cases are not recom-mended.Levels of evidence are defined as follows in theguideline:Evidence level A:evidence based on multiplerandomized clinical trials(RCT)or meta-analyses.Evidence level B:evidence based on a single RCTor multiple non-randomized controlled studies.Evidence level C:expert consensus opinion onlyand/or based on small size studies,retrospectivestudies,and registry study results.Declaration of conflict of interest:all participantsin the guideline revision declared no conflict of in-terest.Highlights of the new 2023 guidelines up-dates compared to the 2016 version are listed in Ta-ble 1.1.EPIDEMIC CHARACTERISTICS OFDYSLIPIDEIMA Key points 1.The main clinically relevant lipid componentsinclude cholesterol and TG.2.Blood cholesterol and TG are mainly found inlipoproteins,including chylomicron(CM),very low-density lipoprotein(VLDL),intermediate-densitylipoprotein(IDL),low density lipoprotein(LDL),high density lipoprotein(HDL)and lipoprotein(a)(Lp(a).Since the 1980s,the Chinese population,includ-ing children and adolescents,has experienced a sig-nificant change in the lipid levels and a marked in-crease in the prevalence of dyslipidemia.1419The average level of lipid components is an im-portant indicator to evaluate the trend of lipid cha-nges in the population.Data from the 2018 nationalGUIDELINEJOURNAL OF GERIATRIC CARDIOLOGYhttp:/;623survey18 showed that for Chinese adults aged 18years,the average serum TC was 4.8 mmol/L,LDL-C was 2.9 mmol/L,and TG was 1.7 mmol/L.Com-pared with the data obtained from the national sur-veys conducted in 2002,2010,and 2015 respectively,the average levels of all lipid components were sig-nificantly higher.14,17 A recently published globalstudy19 reported that in 1980,the average levels ofTC and non-high-density lipoprotein cholesterol(non-HDL-C)in Chinese adults were in a relativelylow tier and significantly lower than those in West-ern countries;whereas in 2018,the average levels ofTC and non-HDL-C in Chinese adults were equival-ent to or exceeded the average levels in certainWestern countries.Meanwhile,lipid levels in chil-dren and adolescents also showed an elevatedtrend.A study on child and adolescent metabolicsyndrome in Beijing15 demonstrated that the aver-age serum TC,LDL-C,and non-HDL-C levels ofchildren and adolescents aged 6 to 18 years in 2014were 4.3,2.4,and 2.8 mmol/L respectively,whichwere significantly higher than those reported10years ago.Elevated level of serum cholesterol is ex-pected to lead to an increase of approximately 9.2million cardiovascular events in China between2010 to 2030.20 Mitigating this continued rise in themean serum cholesterol level is an important goalfor ASCVD prevention in China.The prevalence of adult dyslipidemia in Chinahas remained high in recent years.17,18,21 The resultsof the 2018 national survey demonstrated that theprevalence of dyslipidemia among adults aged 18years was 35.6%,18 which was higher comparedwith the 2015 national survey.17 The increase inprevalence of hypertriglyceridemia(TC 6.2 mmol/L