Recently we published the news about large-scale scientific review, the authors stated that the role of cholesterol in the development of cardiovascular diseases proven insufficient, and the benefits of statins, reducing its level in the blood, is extremely doubtful.
The authors of this study for many years was known for his anticholesterolemic position, and their loud statements may confuse thousands of patients. Edition XXI VEK asked to comment on the work of cardiologist, PhD, researcher of the research Department of cardiology, First MSMU n. a. I. M. SechenovYaroslav Ashikhmina. Mednovosti give this review without notes.
You need to very clearly separate the statins pervichnoi prevention Ivo secondary. Secondary prevention is when cheloveka already had a stroke or a heart attack or, at least, there is confirmed ischemic heart disease. That here statins are the most effective means of preventing repeat heart attacks insultos, ukogo there is no doubt. If cheloveka already had a heart attack or stroke, it is unnecessary to measure any cholesterol to decide naznachenii of statins. Such patients should receive them automatically.
As for primary prevention, regarding the appointment of statins to people kotoryh no heart attacks or strokes, no surprise for me personally vrezultate that review fiction. The position of statins pervichnoi prevention have never not been strong. It is easily explained: to the statin worked, cheloveka should be formed atherosclerotic plaque (or should be a very high risk that it will grow very quickly). Statins work regardless of by reducing cholesterol, Aza account of the fact that strengthen a fibrous tyre atherosclerotic plaque. After the use of statins, it becomes less prone to rupture and dense.
We had decided naznachenii of statins pervichnoi prevention? If to not speak about specific cases, such as the presence of cheloveka family with heterozygous form of hypercholesterolemia, we have previously assessed the risks of the patient with the help of special calculators. The risk of heart attack insult, that is, diseases vosnove which is the risk of rupture of an atherosclerotic plaque. Modelah, osnovanii employing these calculators takes into account gender, age, attitude kuriniu, pressure uroven cholesterol. If the risk according to the analysis of these factors was assessed as high, the person prescribed statins. We in this case had a wide population of different patients, kotoryj could grow plaque. But may ine grow.
It can be assumed that the higher the risk of formation of plaques, Azat risk of plaque rupture, the higher effektivnosti of the statin. But the modern world many people are committed to a healthy lifestyle, imnogie get drugs to reduce blood pressure. Therefore, it may be that the model itself works well because it is a promotion for the population of people plaque neochen often develop for any reason. Udochki application of statins just nebudet.
Now literally during с2016 to 2018 profilaktika was a shift of paradigm. We try to assign statins pervichnoi prevention neem patients kotoryh calculators show high risks, then who got the greatest benefit from statins in clinical research. Fakih patients turned out to be wrong a lot. Basically, these are patients saharnym diabetes pazienti with high levels of C-reactive protein (JUPITER research). In this case, interestingly, they can be quite low levels of low-density lipoproteins of cholesterin. Systemic inflammation Vetom case can play an important role in formirovanii atherosclerotic plaques to sozdavat substrate, the field of action for statins.
But we go further, it’s my research project deals with the preventive concept of 3.0. Even if we take intrachem statins to those populations of patients who definitely benefit from statin initiation, Sonam hand, we can still assign statins unnecessarily. The point is that in this situation we still use population, Ana an individualized approach specific patient Yiwu substrate may nebyt. On the other hand, the risk model newslocal ina important factors associated with the imminent growth of plaques, for example, early family history of heart attack, high levels of social stress, the presence of rheumatic diseases and so on. That is, andá this approach is imperfect.
But within the framework of the concept of 3.0 is possible to make a prescription of statins is really individualized it is necessary to see whether the developed cheloveka plaques on the background of all those risk factors that he had. One thing to consider virtual risks adrogue to hold a low computed tomography of the heart to evaluate the presence of plaques. In this study (means the assessment of calcium score) the radiation load is comparable mammografia, but it helps to know whether an atherosclerotic plaque.
The MESA study has given us a reason to use a CT input of the decision naznachenii of statins in the patients from the groups of medium and low risk. In the presence of additional factors, noise riskovoi models, administration of statins may be appropriate.
Thus, the statin is one of the tools to reduce cardiovascular mortality. But this tool works only through the strengthening of the tires of an atherosclerotic plaque. If we know exactly what plaque is, statins, you need to assign, especially if the plaque has already ruptured. If plaque is not, it should be understood that the appointment of statins used aoni life is a very serious decision for the adoption of which requires a deep understanding. Got no reason to believe that statins are effective Shirokih populations of patients without heart disease. Utaka patients may be higher chance to die from trauma or from cancer, than from heart attack or stroke. Or from heart failure, unrelated aterosklerozom: for example, due to ventricular tachycardia (athletes), alcoholic heart disease (our compatriots), heart failure associated with hipertonia. In these diseases there is also no point for the application of statins.
Another issue when reading such articles, people often decide that statins are not useful to them personally. But Unas incountry disaster tems that statins nenaznachayut those patients who have already suffered a heart attack or stroke. Nedistilata target numbers of cholesterol (of those, ukogo there was a stroke or heart attack, you need to go amaximal aggressive therapy to achieve recommended LDL levels, less than 1.5 to 1.8 mmol/l). These figures show that the dose of statin, sufficient to stabilize plaque, by itself, decrease cholesterol nesmetal, that is, cholesterol is simply a marker. If there is any indication of the strength of the plaque, the need to measure cholesterol in this context will disappear. But it is very important that people have irrevocable statins, because we also these drugs often nenaznachayut when needed, not Vice versa.
You can extend this to saying that the body is so complicated that there is a huge scepticism in respect of medical influences for the purpose of prolonging life (I’m talking, of course, olucak when no disease). Failed aspirin as a primary prevention has failed many other medications. There is no reason to believe that the so-called mythical geroprotectors, will also demonstrate efficacy. I suggest people to accept tems, coaches we don’t have and, most likely, the next time will be no medical procedures for the effective prevention of death Uluda feeling healthy ibez clear significant genetic substrate responsible for early death(such as QT prolongation or a family with heterozygous form of hypercholesterolemia). But drugs can certainly greatly enhance quality of life.