JAMA：增加脂质相关性标记物与心血管疾病预测的略微改善有关

芝加哥–据6月20日刊《美国医学会杂志》JAMA上的一项研究披露，在那些没有已知心血管疾病（CVD）的人中，在含有总胆固醇和高密度脂蛋白胆固醇（HDL-C）的风险评分中加入某些载脂蛋白和脂蛋白与CVD预测的略微改善有关。

英国剑桥大学的Emanuele Di Angelantonio，M.D.及其在“新出现风险因素协作”写作组的同事开展了一项研究，旨在确定在总胆固醇和HDL-C中加入有关载脂蛋白B和载脂蛋白A-I、脂蛋白（a）、脂蛋白相关性磷脂酶A2等信息是否会改善CVD的风险预测。对这项研究而言，在研究开始（病人招募的日历年：1968-2007）的时候，研究人员可获得16，5544名参与者的个人纪录，这些参与者没有CVD而在一个中位数（中点）为10.4年的随访中发生了多达1，5126例致命性或非致命性CVD结果（1，0132例冠心病 [CHD] 及4994例中风）。

研究人员发现，用不同的脂质参数来取代总胆固醇和HDL-C信息没有改善对CVD的预测。“例如，下列的检测中没有一项在用它们取代了风险预测评分中的传统的胆固醇检测时会比总胆固醇和HDL-C更优越：总胆固醇：HDL-C比例；非HDL-C；载脂蛋白B及A-I的线性组合；或载脂蛋白B：A-I比例。此外，用载脂蛋白B及A-I来取代总胆固醇和HDL-C实际上还会明显地使风险区分能力变差。”

文章的作者确实发现，在总胆固醇、HDL-C和其它常规性风险因子中增加不同的脂质相关性标记会改善该模型的区别能力。“我们估计，对10万名年龄在40岁或以上的成年人来说，仅用常规的风险因子来划分的话，有1，5436人最初会被归类为有中等风险。结合载脂蛋白B和A-I、脂蛋白(a)、脂蛋白相关性磷脂酶A2质量所做的额外测试可重新将1.1%、4.1%、2.7%的人做出重新分类，使其预测的CVD风险部类提高20%或以上；因此，根据《成年人治疗小组III指导方针》他们需要接受他汀类药物的治疗。”

然而，文章的作者写道“使用任何一种这类的生物标记的临床裨益还有待确立。”

doi:10.1001/jama.2012.6571
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Lipid-Related Markers and Cardiovascular Disease Prediction

The Emerging Risk Factors Collaboration*

Context The value of assessing various emerging lipid-related markers for prediction of first cardiovascular events is debated. Objective To determine whether adding information on apolipoprotein B and apolipoprotein A-I, lipoprotein(a), or lipoprotein-associated phospholipase A2 to total cholesterol and high-density lipoprotein cholesterol (HDL-C) improves cardiovascular disease (CVD) risk prediction. Design, Setting, and Participants Individual records were available for 165 544 participants without baseline CVD in 37 prospective cohorts (calendar years of recruitment: 1968-2007) with up to 15 126 incident fatal or nonfatal CVD outcomes (10 132 CHD and 4994 stroke outcomes) during a median follow-up of 10.4 years (interquartile range, 7.6-14 years). Main Outcome Measures Discrimination of CVD outcomes and reclassification of participants across predicted 10-year risk categories of low (<10%), intermediate (10%-<20%), and high (≥20%) risk. Results The addition of information on various lipid-related markers to total cholesterol, HDL-C, and other conventional risk factors yielded improvement in the model's discrimination: C-index change, 0.0006 (95% CI, 0.0002-0.0009) for the combination of apolipoprotein B and A-I; 0.0016 (95% CI, 0.0009-0.0023) for lipoprotein(a); and 0.0018 (95% CI, 0.0010-0.0026) for lipoprotein-associated phospholipase A2 mass. Net reclassification improvements were less than 1% with the addition of each of these markers to risk scores containing conventional risk factors. We estimated that for 100 000 adults aged 40 years or older, 15 436 would be initially classified at intermediate risk using conventional risk factors alone. Additional testing with a combination of apolipoprotein B and A-I would reclassify 1.1%; lipoprotein(a), 4.1%; and lipoprotein-associated phospholipase A2 mass, 2.7% of people to a 20% or higher predicted CVD risk category and, therefore, in need of statin treatment under Adult Treatment Panel III guidelines. Conclusion In a study of individuals without known CVD, the addition of information on the combination of apolipoprotein B and A-I, lipoprotein(a), or lipoprotein-associated phospholipase A2 mass to risk scores containing total cholesterol and HDL-C led to slight improvement in CVD prediction.