1、控制心血管危险因素：来自台湾的经验和教训 Risk Factor Control for Cardiovascular Disease: lessons from Taiwan,Ta-Chen Su, MD, PhD Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine Email: tachensuntu.edu.tw,Cardiovascular Disease Prevention,WHO report
2、on CVD prevention: (2003, 2006)1. A population Strategy2. A high-risk strategy3. A secondary prevention strategy Clinical strategies: primary and secondary prevention1. CVD risk factors, single or multiple or total 2. All patients with atherosclerotic CVD,Wood et al. Dialogues in Cardiovascular Medi
3、cine 2009;14:83,Population Strategy (群體策略）,Evidence of hypertension control in Taiwan, 1993-2002 2002-2007 follow-up study: 1. 3H and incidence of CVD2. Trends of 3H and Metabolic syndrome The Chin-Shan Community Cardiovascular Cohort (CCCC) Study in Taiwan Early Atherosclerosis Study in Young Adult
4、,2002台灣地區三高（高血壓、高血糖、高血脂）調查,Evidence for Improved Control of Hypertension in Taiwan: 1993-2002,2002 Taiwanese Survey on Hypertension, Hyperglycemia, and Hyperlipidemia (TwSHHH) Su et al, J Hypertens 2008; 26;600-608.,The Taiwanese Survey on Hypertension, Hyperglycemia, and Hyperlipidemia (TwSHHH) 200
5、2,TwSHHH is the second nationwide survey, which was designed to assess the prevalence, awareness, treatment, and control of hyperglycemia, hyperlipidemia, and hypertension during 2002 Applied a multi-stage, stratified, and random sampling during 2002 with a total of 7566 participants from 1,648 Neig
6、hborhoods (鄰) of 68 precincts/ townships (鄉鎮市區) in Taiwan.Su et al. J Hypertens 2008;26:600-6.,Figure 1-1 Prevalence of Hypertension in the Taiwanese Populations, NAHSIT vs. TwSHHH,Figure 1-2 Prevalence of Hypertension in the Taiwanese Populations, NAHSIT vs. TwSHHH,Figure 1-3 Prevalence of Hyperten
7、sion in the Taiwanese Populations, NAHSIT vs. TwSHHH,Age group,Male,Figure 1-4 Prevalence of Hypertension in the Taiwanese Populations, NAHSIT vs. TwSHHH,Age group,Female,Figure 1-5 Prevalence of Hypertension in the Taiwanese Populations, NAHSIT vs. TwSHHH,Body mass index, Kg/m2,BMI,Table 3 Trends i
8、n Hypertension Awareness, Treatment, and Control in the Adult Population during Two Nationwide Surveys in Taiwan, P 0.001, for differences in hypertension awareness, treatment, and control between the NAHSIT and TwSHHH,Why attribute to NHI ?,Before the National Health Insurance (NHI) was introduced
9、in 1995, the uninsured people are those of retired, elderly, disables, women, students, and children. The uninsured were deterred from seeking necessary medical services, and this created unequal access to health care between socioeconomic classes. After implementation of NHI in March 1995, these po
10、pulations could access to health care system without economic barriers, as Figure.1 Another supporting evidence: Mortality rate ofStroke from 64.77/105 in 1994 to 53.46/105 in 2002 Heart disease from 56.93/105 in 1994 to 50.93/105 in 2002.2,(1). Rachel Lu et al. Health affairs. 2003; 22: 77-88. (2).
11、 Vital statistics 2005, Taiwan. http:/www.doh.gov.tw/statistic/data/94/8.xls,Rachel Lu JF, Hsiao WC. Does universal health insurance make health care unaffordable? Lessons from Taiwan. Health Affairs 2003; 22: 77-88.,Coverage of National Health Insurance in Taiwan,1995,2002-2007 Follow-up Survey in
12、Taiwan 台灣地區2002-2007三高變遷之調查,台灣地區三高調查2002-2007年之變遷 高血壓盛行率,台灣地區三高調查2002-2007年之變遷 高血糖（糖尿病）盛行率,台灣地區三高調查2002-2007年之變遷 高膽固醇血症盛行率,台灣地區三高調查2002-2007年之變遷 高三酸甘油酯血症盛行率,全國三高調查2002-2007年之變遷 高低密度膽固醇盛行率,台灣地區三高調查2002-2007年之變遷 低高密度膽固醇盛行率,台灣地區三高調查年之變遷 代謝症候群盛行率,20022007年三高罹患心臟病之發生風險,20022007年三高罹患腦中風之發生風險,20022006年三高之全
13、死因風險,Relative risk ratio was estimated by using Coxs proportional hazards model,2002-2007年三高之變遷,高血壓、高低密度膽固醇(Male)、代謝症候群之盛行率增加 三高與新發生心血管疾病及死亡率皆密切相關,The Chin-Shan Community Cardiovascular Cohort (CCCC) Study in Taiwan 台灣金山社區心臟血管疾病世代研究,A longitudinal prospective cohort study conducted since 1990-1991 i
14、n Chin-Shan community, Taipei, Taiwan Population: 35 years-old and above, 6 month Exam: Biannual follow-up of physical examinations, electrocardiogram, glucose, lipid profile, urine, echocardiogram, and carotid duplex End-points: newly onset of DM, Hypertension, and CVD morbidity and mortality,Lee e
15、t al. J Clin Epidemiol 2000 Su et al. Stroke 2001; Chien et al. Stroke 2002 Chien et al. Diabetologia 2009; Clin Chem 2008.,The Chin-Shan Community Cardiovascular Cohort (CCCC) Study in Taiwan,Chin-Shan: a sub-urban community 40 kilometers outside the metropolitan Taipei in northern Taiwan Area: 49.
16、21 square kilometers Population: 18,728 (men: 9907, women: 8821) in 1990. =35 years old: 4349 Inclusion: 3,602 residents, (82.8% response rate) Men: 1703 (47.3%), Women: 1899 (52.7%),Chin-Shan,Taipei,Table Model for risk factor profiles to predict cardiovascular events in the Chin-Shan Community Car
17、diovascular Cohort (CCCC) study, Taiwan,Chien et al. J Hypertens 2007;25:1355,1990 F/U CVD at 2005 (122 CHD, 210 Stroke),Multivariate adjusted relative risk of hypertension incidence during a median 7.9 years of follow-up according to quartiles of urinary sodium excretion and BMI as well as blood pr
18、essure status. Cutoff points for the quartiles of urinary sodium excretion were less than 84 mmol, 84-122 mmol, 122-178 mmol and at least 178 mmol and cutoff points as the medium values of BMI (22.7kg/m2) and systolic blood pressure (116mmHg).,Chien et al. J Hypertens 2008;26:1750,Urine Sodium and P
19、otassium Excretion and Risk of Hypertension,尿中鈉的排泄量與高血壓發生風險有關，在中國人可以用其當做飲食中鈉鹽攝取之指標。,a Adjusted for age, BMI and DBP at baseline. b Adjusted for variables in model 1 as well as occupation, smoking, alcohol consumption and exercise at baseline. c Adjusted for variables in variables in model 2 and LDL
20、and TG. d Adjusted for variables in model 3 and menopausal status. Chen et al. J Hypertens 2009;27:1370,Table Hazard ratio(95% confidence interval) of incident hypertension during follow-up period in relation to BMI change (2 years: 19901993 F/U at 2000),兒童時期與現在心血管因子的變化與年輕成年人心血管危險因子及早期動脈硬化的風險 Change
21、s of CVD Risk Factors between Childhood and Adulthood, and the Risk of Early Atherosclerosis in Young Adult,128,413 students with twice of positive urine screening,Excluded 24,561 with unreliable BP 96 with unknown urine screening,9227 with HTN,94529 with no HTN,5753 with address,59855 with address,
22、1251 in Taipei area,17448 in Taipei area,303/1336 received CV examination Response rate = 22.7 %,487/3850 received examination Response rate = 12.6 %,Only via Mail,Via Telephone and Mail,3474 with no address,34674 with no address,平均12.5歲的青少年有兩次以上有尿液 異常者，約九年後邀請回台大醫院接受心 血管及血液檢查（頸動脈內中皮厚度）,2006-2008年Tai
23、pei Area總共有791位接受追蹤,Table 2-1 CVD Risk Factors Stratified by BMI,Table 2-2 CVD Risk Factors Stratified by BMI,BMI,SBP,DBP,CHO,Glucose,Childhood CV risk factors,Adulthood CV risk factors,2.32,1.97,0.89,1.17,6.88,2.13,1.53,1.36,1.03,1.11,Cardiovascular Risk Factors in Childhood and Thicker IMT in Adul
24、thood,Carotid IMT 75th percentile,Childhood,Adulthood,1,2,O.R.,BMI 85th percentile,BMI 85th percentile,3,4,5,6,1,1.48,3.12,7,8,9,10,11,1.03,3.32,5.58,*,Change of BMI and Risk of High BP in Young Adult,Prehypertension or Hypertension,1,2,O.R.,BMI 85th percentile,BMI 85th percentile,Childhood,Adulthoo
25、d,3,4,5,6,1,1.17,0.85,1.12,2.99,3.33,+,Change of BMI and Risk of Thicker Carotid IMT in Young Adult,IMT 75th percentile,結 論,青少年肥胖與血壓與年輕成年時早期動脈硬化有關 青少年時期肥胖與心血管危險因子皆會影響其年輕成年時之肥胖與心血管危險因子,A high-risk strategy (Familial Hypercholesterolemia),A secondary prevention strategy (PCI for AMI Patients),Genetic
26、Study of Familial Hypercholesterolemia in Taiwan,家族性高膽固醇血症,Methods,Cascade screening for FH FHChip (a resequencing microarray) for index case MLPA (Multiplex ligation-dependent probe amplification) for those without findings,Tsais Family,54 444 172 43 367,30 182 211 52 79,15 129 59 50 62,49 192 36 5
27、8 106,53 210 205 43 139 用藥中,51 425 82 67 328,44 163 85 44 99,27 226 74 74 118,54 243 125 51 158,28 144 80 44 75,27 152 45 51 75,25 205 99 53 132,28 171 86 54 98,27 367 140 38 301,49 236 281 41 139,Age TCHO TG HDL LDL,LDLRexon02 Dup LDLRexon03 Dup LDLRexon04 Dup LDLRexon05 Dup LDLRexon06 Dup,20 539 8
28、1 43 362,25 167 92 53 96,Pans Family,50 272 108 72 178,24 141 51 43 64,Age TCHO TG HDL LDL,LDLRexon03 GR at 268 D69D,N,LDLRexon07 GR at 986 C308C,Y,Table 3 Lipids levels and cardiovascular characteristics in single mutation and complex mutations of heterozygous familial hypercholesterolemia,Complex
29、mutations include compound heterozygote, Single allele double mutations, and large chromosome mutations,Conclusions,Most FH are heterozygote and higher rate of complex mutations (compound heterozygote or single allele double, or large chromosome) were found in this study. MLPA have some important ro
30、le in patients with severe hypercholesterolemia and tendon xanthoma but without point mutations found. Most patients have good response to combination therapy with statins and Ezetamibe. Treating FH: High-risk patients approach 治療家族性高膽固醇血症即是高危險群策略的例子,Long-term outcomes of elective PCI either with or
31、 without prior fibrinolysis vs. primary PCI in patients with AMI,Methods,We retrospectively collected data from detailed chart review for patients with AMI through 1994 to 2000 in National Taiwan University Hospital (NTUH). Patients with first time diagnosis of AMI and received PCI with or without T
32、T within 28 days were registered and matched for the mortality at 2006. Primary endpoints included mortality of all-cause, cardiovascular disease (CVD, ICD-9 code 390-459), and coronary heart disease (CHD, ICD-9 code 410-414) was compared in different reperfusion strategies. Cox proportional regress
33、ion analyses were applied to estimate the hazards ratio of different reperfusion strategies and other prognostic factors.,Table 1 Baseline Characteristics of the Patients According to Register Strategy,All-cause Mortality,CVD Mortality,CHD Mortality,All-cause Mortality,接受TT+PCI 或 Elective PCI 者，在兩星期
34、接受 PCI治療者，預後較好。,Note: MRO as reference group; TT, thrombolytic therapy, mainly tissue-type plasminogen activator,Late Open Never Too Late,Long-term beneficial effect of late reperfusion for AMI with PCI in some randomized trials (Horie, Circulation 1998), in stable survivors of AMI (Zeymer, Circulat
35、ion 2003), and ACS with prior CABG in a national registry (Held, EHJ 2007) Meta-analysis showed better outcome for delayed PCI (JACC 2008), Routine PCI after Fibrinolysis (NEJM 2009 June) Mechanism: patent IRA, improved LV function, prevent LV dilation and beneficial LV remodeling,NCEP ATP III Guide
36、line for ACS Patients,NCEP ATP III Guideline建議 所有因急性冠心病而住院的 病人都應積極使用Statin治療,Circulation. 2004;110:227-239,2007 ACC/AHA guideline for STEMI - Lipid Management,JACC 2008; 51:21047,STEMI 病人最好能將其低密度膽固醇降低至 70 mg/dL,2007 ACC/AHA guideline for UA/NSTEMI - Lipid Management,JACC 2007;50:652726,2007 ACC/AHA
37、guideline建議, 針對 UA/NSTEMI的病人,不管 其LDL-C的baseline為何,均應 給予Statin積極治療, 治療目標 為LDL-C 100mg/dl, 理想的 治療目標為LDL-C70mg/dl,結 論,急性心肌梗塞病人應積極介入治療，若未能馬上接受(Primary PCI)，也能在28天內（最好在一至二星期內）給與經皮冠狀動脈血管介入性治療，長期追蹤其預後是相當好。 急性心肌梗塞病人，無論哪一種治療，若能給與Statins，其預後會較好。,Conclusions 總結,群體策略：國家衛生政策及行政 臨床策略：經由醫師及衛生相關專業團隊共同努力 高危險群策略：高膽固醇
38、、高血壓、高血糖、肥胖、代謝症候群、吸煙 續發性預防策略：積極教育及治療冠心病病患、腦中風病患 我們需要的策略是好的群體策略而非個人策略 Treating sick population is more important than treating sick individuals. 要預防心血管疾病，高危險群介入治療是不夠的，必須群體策略與高危險群策略兼顧。 政府、醫師、藥廠、保險團體一起合作,Acknowledgements,Yuan-Teh Lee, MD, PhD Ming-Fong Chen, MD, PhD Chiau-Suong Liau, MD, PhD Kuo-Liong
39、Chien, MD, PhD Fung-Chang Sung, MPH, PhD Jung-Der Wang, MD, DSc Chien-Jen Chen, MPH, DSc Chang-Chuan Chan, MPH, DSc Jiann-Shing Jeng, MD, PhD Pao-Ling Torng, MD, PhD Ming-Jen Lee, MD, PhD Hsio-Chin Hsu, PhD,Cardiologists in NTUH Bao-Show Hwang, BS Ms. Ching-Ju Chien Ming-Ying Chang, BS Chen-Fang Che
40、n, MS Ms. Lising Hsu,Prevalence of Hyperlipidemia in Men高血脂症,單位： mg/dl,Prevalence of Dyslipidemia in Women 高血脂症,單位： mg/dl,2002台灣地區三高（高血壓、高血糖、高血脂）調查：高血脂症,大於15歲人口（18,564,171人）中，有10.2 %屬高膽固醇血症，即有約190萬人膽固醇超過240 mg/dl。（男性9.9%，女性10.4%) 有約280萬人屬高三酸甘油酯血(TG200 mg/dl)。（男性20%，女性11%) 好的膽固醇偏低者，有約300多萬人屬膽固醇分佈不好的不
41、良血脂症。 總之，台灣地區約有四分之一以上的成年人屬於高血脂症的病人，高脂血症絕對是國人健康的大患，值得大家來重現。,1,2,O.R.,HDL,LDL,TG,HCHO/HDL,ApoB/ApoA1,1.02,1.64,1.13,1.34,1.13,Adulthood Lipids and Risk of Thicker IMT (75th percentile),Study Patients,Inclusion criteria: Cholesterol 290 mg/dl and LDL 190 and at least one family members with the same HC
42、HO. Premature CAD, tendon xanthoma, corneal arcus. Exclusion criteria: Hypothyroidism, cholestatic jaundice, nephrotic syndrome, malignancy, receiving C/T or steroids During 7 years (2002-2008), We recruited 80 Families included 450 family members for this study.,Conclusions,There was a significant
43、improvement of hypertension awareness, treatment, and control in TwSHHH survey compared with the NAHSIT survey in Taiwan. TwSHHH results correlated in time with the implementation of National Health Insurance since 1995. The favorable changes in education and availability of health care may account for improved control of hypertension and, possibly, its prevention.,
