2009년 2학년 2학기 혈액종양학 강의평가
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1 고지혈증치료의최신지견 Chung-Ang Cardiovascular Therapeutics 2017 이상엽, M.D., Ph.D. 충북권역심뇌혈관센터, 충북대학교병원
2 목차 고지혈증의국내현황 스타틴사용의최신지견 스타틴이외약물의최신지견 고지혈증치료제고시개정안
3 고지혈증치료의최신지견 : 스타틴과진료지침의변화 ATP I 1993 ATP II 2001 ATP III 2004 ATP III update 2011 ESC 2013 ACC 2014 KSoLA 2016 ESC ACC
4 진료지침의진화 ( 미국 ) ATP 1,2,3 그리고 2013, 2016 ATP I 1988 ATP II 1993 ATP III 2001 ATP III Update 2004 Exclusive focus on LDL-C Risk assessment guides therapy Lower LDL-C threshold for therapy initiation in highrisk patients Lower LDL-C threshold for therapy initiation in veryhigh-risk patients Strong support for resins, niacin LDL-C goal reduced for CHD (<100mg/dL) LDL-C goal <100 mg/dl for CHD equivalent Optional LDL-C goal < 70 mg/dl for CVD+multiple/severe risk or ACS Statins, fibrates not first line Statins included in "major drugs," fibrates for mixed HPL Non-HDL-C and metabolic syndrome as secondary targets Optional LDL-C goal < 100 mg/dl for moderately high-risk primary prevention Low-to moderate-dose monotherapy Moderate-to high-dose statin High-dose statin, increased combination therapy
5 미국진료지침개정 2013 (ACC/AHA) More aggressive target for very high-risk patients ATP I 1993 ATP II 2004 ATP III 2011 ESC 2013 ACC AHA 2015 KSoLA 2016 ESC ACC AHA
6 2013 ACC/AHA Guideline 기존 NCEP ATPIII 가이드라인 Risk Category CHD &CHD 에준하는위험 (T2DM 포함 ) LDL-C Goal (mg/dl) <100 위험요인 2 개이상 <130 위험요인 0-1 개 < ACC/AHA 가이드라인 ASCVD Statin 이점그룹 ASCVD 예방을목적으로함 ASCVD 환자 NO LDL-C 190mg/dL YES 75 세 : 고강도 >75 세 or 이상반응및약물상호작용 : 중강도 고강도 Statin # 4 statin benefit groups 1. Clinical ASCVD인환자 2. LDL-C 190mg/dl 이상 3. 당뇨이며, LDL-C가 70~189 mg/dl인 40~75세 4. Clinical ASCVD나당뇨가아닌 LDL-C가 NO Diabetes Type 1 or 2, 나이 NO 중강도 Statin 10y ASCVD risk 7.5% : 고강도 Statin 70~189 mg/dl인 40~75세, 10y ASCVD risk 7.5% 이상 10 y ASCVD risk 측정 7.5% & y YES 중강도 Statin
7 미국진료지침개정 2013 (ACC/AHA) More aggressive target for very high-risk patients
8 2013 ACC/AHA Guideline 스타틴강도분류 High-Intensity Statin Therapy ( 고강도 ) Moderate-Intensity Statin Therapy( 중강도 ) Low-Intensity Statin Therapy ( 저강도 ) Daily dose lowers LDL-C on average, by approximately 50% Atorvastatin (40 )-80mg Rosuvastatin 20 (40)mg Daily dose lowers LDL-C on average, by approximately 30% to <50% Atorvastatin 10(20)mg Fluvastatin 40mg bid Pitavastatin 2-4mg Pravastatin 40(80) mg Rosuvastatin (5) 10mg Simvastatin 20-40mg Daily dose lowers LDL-C on average, by <30% Fluvastatin 20-40mg Lovastatin 20mg Pitavastatin 1mg Pravastatin 10-20mg Simvastatin 10mg ACC : American College of Cardiology ( 미국심장학회 ) AHA : American Heart Association ( 미국심장협회 )
9 Highlights from the recently published 2016 ACC Expert Consensus Decision Pathway on the role of non-statin therapies ATP I 1993 ATP II 2004 ATP III 2011 ESC 2013 ACC AHA 2015 KSoLA 2016 ESC ACC AHA Threshold LDL-C levels can be considered when deciding whether to use non-statin therapies in select high-risk patients Group Clinical ASCVD, age 21 years Thresholds on Maximally Tolerated Statin Therapy Thresholds on Maximally Tolerated Statin Therapy Stable and without comorbidities <50% LDL-C reduction or LDL-C 100 mg/dl Ezetimibe With comorbidities <50% LDL-C reduction or LDL-C 70 mg/dl Ezetimibe With baseline LDL-C 190 mg/dl (not due to secondary causes) <50% LDL-C reduction or LDL-C 70 mg Ezetimibe or PCSK9 inhibitor Without clinical ASCVD Baseline LDL-C 190 mg/dl (not due to secondary modifiable causes), age 21 years Diabetes, age years with baseline LDL-C mg/dl No diabetes, age years, with baseline LDL-C mg/dl, 10-year ASCVD risk of 7.5%, <50% LDL-C reduction or LDL-C 100 mg/dl Ezetimibe or PCSK9 inhibitor <50% LDL-C reduction or LDL-C 100 mg/dl or non HDL-C 130 Ezetimibe <50% LDL-C reduction or LDL-C 100 mg/dl Ezetimibe
10 2016 A Consensus Statement on Lipid Management after Acute Coronary Syndrome Decision algorithm at admission. Schiele F, et al. Eur Heart J Acute Cardiovasc Care. 2016
11 2016 A Consensus Statement on Lipid Management after Acute Coronary Syndrome Decision algorithm at follow-up Schiele F, et al. Eur Heart J Acute Cardiovasc Care. 2016
12 18.1% 15.3% 20.2% 22.4% 20.7% 31.1% 34.3% 30.8% 28.1% 32.6% 37.4% 33.7% 29.6% 33.8% 38.3% 43.0% 48.8% ACS/CHD patients did not achieve LDL-C <70 mg/dl in Korea 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 38.3% 43.0% 40.0% 30.0% 20.0% 10.0% 0.0% AP Total Hong Kong India Indonesia Philippines Singapore South Korea Taiwan Thailand Vietnam ACS Cohort CHD Cohort LeeSH et al., Global Heart 2015;10(2 Suppl): April 29 - May th Asian Pacific Society of Cardiology Congress World Congress of Echocardiography and Allied Techniques 6th Emirates Cardiac Society Congress, Adnec, Abu Dhabi
13 미국당뇨병협회 Standards of Medical Care in Diabetes 2016 Cefalu et al. Diabetes Care 2016; 39 (Suppl. 1): S60-S71.
14 2016 ESC/EAS Guidelines 유럽진료지침 for the Management of Dyslipidemias LDL-C Non HDL-C Apo B Primary Target Secondary Targets Very high risk Documented CVD, previous AMI, ACS, coronary or other arterial revascularization, stroke, TIA, aortic aneurysm, PAD, DM with target organ damage (such as proteinuria or with a major RF such as smoking or marked hypercholesterolemia or marked hypertension), severe CKD (GFR <30mL/min/1.73m 2 ), or a calculated 10 year risk SCORE 10% <70mg/dL or 50% reduction from baseline between mg/dl <100mg/dL <80mg/dL High risk Markedly elevated single risk factors such as familial dyslipidemia and severe hypertension, most other people with DM, moderate CKD (GFR 30-59mL/min/ ) or a calculated SCORE 5% and <10% for 10 year risk of fatal CVD <100mg/dL or 50% reduction from baseline between mg/dl <130mg/dL <100mg/dL Moderate risk SCORE is 1% and <5% at 10 years, many middle-aged subjects <115mg/dL <145mg/dL Not defined Catapano AL, et al. Eur Heart J Aug;23(11):NP1-NP96.
15 2016 ESC/EAS Guidelines Recommendations 유럽진료지침 for the pharmacological treatment of hypercholesterolaemia Catapano AL, et al. Eur Heart J Aug;23(11):NP1-NP96.
16 유럽진료지침의비교 2011 년 vs 년 May be -> Should be Class of recommendation and level of evidence has been ascended from IIb,C to IIa, B.
17 한국지질동맥경화학회이상지질혈증치료지침 2015 년 3 판 ATP I 1993 ATP II 2001 ATP III 2004 ATP III update 2011 ESC 2013 ACC 2015 KSoLA 2016 ESC ACC 2014 국내고시개정
18 한국인의이상지질혈증진단기준 한국지질동맥경화학회이상지질혈증치료지침 2015 년 3 판 H
19 한국지질동맥경화학회이상지질혈증치료지침 2015 년 H
20 한국지질동맥경화학회이상지질혈증치료지침 2015 년
21 한국지질동맥경화학회이상지질혈증치료지침 2015 년
22
23 진료지침의핵심내용 LDL-C 저하가치료의 1 차목표이다. 초고위험군 ( 죽상동맥경화심혈관질환병력 ) 환자의치료는 LDL-C <70mg/dl 를목표로한다. 치료의 1 차약제는스타틴이다. 스타틴으로목표치에도달하지못하거나부작용이발생한경우 ezetimibe 또는 bile acid sequestrants 사용을고려해야한다. 스타틴최대내약용량이나 ezetimibe 병용치료에도 LDL-C 치료목표에도달하지못한경우나스타틴불내성환자의경우 PCSK9 억제제를고려할수있다. 중성지방 > 200mg/dl 의심혈관질환고위험환자에게약물치료가고려돼야한다.
24 고지혈증치료의최신지견 : ezetimibe 를중심으로
25 미국진료지침 2016 Threshold LDL-C levels can be considered when deciding whether to use non-statin therapies in select high-risk patients Group Clinical ASCVD, age 21 years Thresholds on Maximally Tolerated Statin Therapy Thresholds on Maximally Tolerated Statin Therapy Stable and without comorbidities With comorbidities With baseline LDL-C 190 mg/dl (not due to secondary causes) Without clinical ASCVD Baseline LDL-C 190 mg/dl (not due to secondary modifiable causes), age 21 years Diabetes, age years with baseline LDL-C mg/dl No diabetes, age years, with baseline LDL-C mg/dl, 10-year ASCVD risk of 7.5%, <50% LDL-C reduction or LDL-C 100 mg/dl <50% LDL-C reduction or LDL-C 70 mg/dl <50% LDL-C reduction or LDL-C 70 mg <50% LDL-C reduction or LDL-C 100 mg/dl <50% LDL-C reduction or LDL-C 100 mg/dl or non HDL-C 130 <50% LDL-C reduction or LDL-C 100 mg/dl Ezetimibe Ezetimibe Ezetimibe or PCSK9 inhibitor Ezetimibe or PCSK9 inhibitor Ezetimibe Ezetimibe
26 미국당뇨병협회진료지침 2016 Cefalu et al. Diabetes Care 2016
27 유럽진료지침 2016
28 Ezetimibe : Mechanism of Action
29 Ezetimibe add-on therapy was comparable to 3-step statin up-titration in % LDL-C reduction
30 Additional reduction of LDL-C by ezetimibe add-on Ezetimibe add-on to any statin provided additional 25-31% reduction of LDL-C in 5 separate clinical trials 1-5 0%- Percent changes of LDL-C from baseline statin + placebo statin + ezetimibe 10mg/day -5%- -10%- -15%- -20%- -25%- -30%- -35%- -3% P< % -4% -25% P< % -25% P % -27% P % P % a In hypercholesterolemia patients with CHD. The primary endpoint was the percentage of patients reaching an LDL-C target of 2.6 mmol/l at study endpoint. [Result : Ezetimibe group vs Placebo group, 74.3% vs 16.7%, p 0001) 3 b In CHD patients with hypercholesterolemia. The primary endpoint was the percentage of patients reaching an LDL-C target of 2.6 mmol/l at study endpoint. [Result : Ezetimibe group vs Placebo group, 80.4% vs 17.4%, p 0001) 4 c In hypercholesterolemia patients with CHD. The primary endpoint was the percentage of patients achieving LDL-C 2.6 mmol/l at study endpoint. [Result : Ezetimibe group vs Placebo group, 81.3% vs 21.8%, p 0001) 5 Study design; In 5 separate randomized, double-blind, placebo-controlled trials of patients with hypercholesterolemia (2 of them examined the percent change in LDL-C as a primary endpoint, 3 of them evaluated it as a secondary endpoint), CHD, coronary heart disease, LDL-C, low-density lipoprotein cholesterol 1. Pearson TA et al. Mayo Clin Proc 2005;80: ; 2. Gagné C et al. Am J Cardiol 2002;90: ; 3. Farnier M et al. Int J Cardiol 2005;102: ; 4. Brohet C et al. Curr Med Res Opin 2005;21: ; 5. Cruz-Fernández JM et al. Int J Clin Pract 2005;59:
31 진료지침변화의근거 : IMPROVE-IT 연구 Patients stabilized post ACS 10 days: LDL-C *mg/dL (or **mg/dL if prior lipid-lowering Rx) *3.2mM **2.6mM N=18,144 Standard Medical & Interventional Therapy Simvastatin 40 mg Uptitrated to Simva 80 mg if LDL-C > 79 (adapted per FDA label 2011) Ezetimibe / Simvastatin 10 / 40 mg Follow-up Visit Day 30, every 4 months 90% power to detect ~9% difference Duration: Minimum 2 ½ -year follow-up (at least 5250 events) Primary Endpoint: CV death, MI, hospital admission for UA, coronary revascularization ( 30 days after randomization), or stroke Cannon CP AHJ 2008;156:826-32; Califf RM NEJM 2009;361:712-7; Blazing MA AHJ 2014;168:205-12
32 LDL-C 과지질의변화 1 Yr Mean LDL-C TC TG HDL hscrp Simva EZ/Simva Δ in mg/dl Median Time avg 69.5 vs mg/dl
33 Primary Endpoint ITT 일차연구종말점 : 심혈관질환사망, 심근경색증, 재입원이필요한불한정형협심증또는뇌경색 HR CI (0.887, 0.988) p=0.016 Simva 34.7% 2742 events NNT= 50 EZ/Simva 32.7% 2572 events 7-year event rates
34 LDL Cholesterol 과임상적혜택 a: Gruppo Italiano per lo Studio della Sopravvivenza nell Infarto Miocardico (GISSI Prevenzione)27; b: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial Lipid Lowering Trial (ALLHAT- LLT)28; c: Assessment of Lescol in Renal Transplantation (ALERT)29; d: Lescol Intervention Prevention Study (LIPS)30; e: Air Force/Texas Coronary Atherosclerosis Prevention Study AFCAPS/TexCAPS)31; f: Cholesterol and Recurrent Events (CARE)32; g: Longterm Intervention with Pravastatin in Ischaemic Disease (LIPID)33; h: Prospective Study of Pravastatin in the Elderly at Risk (PROSPER)34; i: Anglo-Scandinavian Cardiac Outcomes Trial Lipid Lowering Arm (ASCOT- LLA)35; j: West of Scotland Coronary Prevention Study (WOSCOPS)36; k: Post Coronary Artery Bypass Graft (Post CABG)37; l:collaborative Atorvastatin Diabetes Study (CARDS)38; m: Heart Protection Study (HPS)2; and n: Scandinavian Simvastatin Survival Study (4S)1. N Engl J Med Jun 18;372(25):
35 고지혈증치료개념의변화
36 IMPROVE-IT 연구이후의변화 고위험, 초고위험군에서더공격적인지질저하치료가의미있다. 스타틴만으로목표에도달하지못하는환자에서 Ezetimibe 를추가 하는치료를고려해야한다. 1. 스타틴최대용량사용에도치료목표에도달하지못한경우 2. 스타틴불내성의경우 3. 스타틴사용금기의경우
37 고지혈증치료제관련국내보험급여기준
38 고지혈증치료제고시개정안 ATP I 1993 ATP II 2001 ATP III 2004 ATP III update 2011 ESC 2013 ACC 2015 KSoLA 2016 ESC ACC 2014 국내고시개정 가. 순수고저밀도지단백콜레스테롤 (LDL-C) 혈증 1) 투여대상가 ) 위험요인 * 이 0 1개인경우 : 혈중 LDL-C 160 mg/dl일때나 ) 위험요인 * 이 2개이상인경우 : 혈중 LDL-C 130 mg/dl일때다 ) 관상동맥질환또는이에준하는위험 ( 말초동맥질환, 복부대동맥류, 증상이동반된경동맥질환, 당뇨병 ) 인경우 : 혈중 LDL-C 100 mg/dl일때라 ) 급성관동맥증후군인경우 : 혈중 LDL-C 70 mg/dl일때 2) 해당약제 HMG-CoA 환원효소억제제, 담즙산제거제, Fibrate계열약제중 1종
39 고지혈증치료제고시개정안 2014 나. 순수고트리글리세라이드 (TG) 혈증 1) 투여대상가 ) 혈중 TG 500 mg/dl일때나 ) 위험요인 * 또는당뇨병이있는경우 : 혈중 TG 200 mg/dl일때 2) 해당약제 Fibrate 계열, Niacin 계열중 1종 다. 고 LDL-C 및고 TG 혈증복합형 1) 투여대상 가. 순수고LDL-C혈증 과 나. 순수고TG혈증 에해당하는경우 2) 해당약제 LDL-C 및 TG에작용하는약제별로각각 1종씩인정 라. 약제투여는치료적생활습관변화 (therapeutic lifestyle changes) 를병행하여실시토록 권장함
40 고지혈증치료제고시개정안 2014 * 위험요인 1 흡연 2 고혈압 (BP 140/90 mmhg 또는항고혈압제복용 ) 3 낮은고밀도지단백콜레스테롤 (HDL-C)(<40 mg/dl) 4 관상동맥질환조기발병의가족력 ( 부모, 형제자매중남자 <55세, 여자 <65세에서관상동맥질환이발병한경우 ) 5 연령 ( 남자 45세, 여자 55세 ) HDL-C 60 mg/dl은보호인자로간주하여총위험요인수에서하나를감한다.
41 고지혈증치료제고시개정안 2016 구분현행개정 ( 안 ) 사유 Ezetimibe 경구제 ( 품명 이지트롤정 등 ) [ 일반원칙 ] 고지혈증치료제 세부사항 에준하여인 [ 일반원칙 ] 고지혈증치료제 세부사항 에준하여교과서, 가이드라인, 정하되허가사항범위내에서아래와같은기준으로투인정하되허가사항범위내에서아래와같은기준임상논문, 학회의견등을 여시요양급여를인정하며, 동인정기준이외에는약값으로투여시요양급여를인정하며, 동인정기준이참조하여 HMG-CoA 전액을환자가부담토록함. - 아래 - 외에는약값전액을환자가부담토록함. - 아래 - reductase inhibitor 의 최대량 문구를삭제함. 가. HMG-CoA reductase inhibitor의최대량을사용가. HMG-CoA reductase inhibitor을사용하였으삭제함. 였으나반응이충분하지않은경우반응이충분하지않은경우또는부작용등으로나. 현재, HMG-CoA reductase inhibitor의최대량이투여할수없거나증량이어려운경우하의용량을사용하고있으나, 나. 2개이상의기존고지혈증치료약물에불응성 1) 병용약물과의상호작용으로인하여최대량으로의혹은금기인경우증량이어려운경우 2) HMG-CoA reductase inhibitor의최대량사용후작용으로인하여용량감량을한경우다. 2개이상의기존고지혈증치료약물에불응성혹은금기인경우
42 증례 1 : 치료는? F 60 고혈압, 고지혈증 T-Chol yr risk 4.8% TG 82 SCORE 3% HDL-C 61 LDL-C 유럽치료지침 LDL-C Primary Target Very high risk Documented CVD, previous AMI, ACS, coronary or other arterial revascularization, stroke, TIA, aortic aneurysm, PAD, DM with target organ damage (such as proteinuria or with a major RF such as smoking or marked hypercholesterolemia or marked hypertension), severe CKD (GFR <30mL/min/1.73m 2 ), or a calculated 10 year risk SCORE 10% <70mg/dL or 50% reduction from baseline between mg/dl High risk Markedly elevated single risk factors such as familial dyslipidemia and severe hypertension, most other people with DM, moderate CKD (GFR 30-59mL/min/ ) or a calculated SCORE 5% and <10% for 10 year risk of fatal CVD <100mg/dL or 50% reduction from baseline between mg/dl Moderate risk SCORE is 1% and <5% at 10 years, many middleaged subjects <115mg/dL
43 증례 1 : 다음치료는? Atorva Atorva SA --> PCI Rosuva20 F 60 고혈압, 고지혈증 T-Chol yr risk 4.8% TG SCORE 3% HDL-C LDL-C 유럽치료지침 LDL-C Primary Target Very high risk Documented CVD, previous AMI, ACS, coronary or other arterial revascularization, stroke, TIA, aortic aneurysm, PAD, DM with target organ damage (such as proteinuria or with a major RF such as smoking or marked hypercholesterolemia or marked hypertension), severe CKD (GFR <30mL/min/1.73m 2 ), or a calculated 10 year risk SCORE 10% <70mg/dL or 50% reduction from baseline between mg/dl High risk Markedly elevated single risk factors such as familial dyslipidemia and severe hypertension, most other people with DM, moderate CKD (GFR 30-59mL/min/ ) or a calculated SCORE 5% and <10% for 10 year risk of fatal CVD <100mg/dL or 50% reduction from baseline between mg/dl Moderate risk SCORE is 1% and <5% at 10 years, many middleaged subjects <115mg/dL
44 증례 2 : 치료는? M 45 NSTEMI, PCI T-Chol 245 TG 144 HDL-C 38 LDL-C 유럽치료지침 LDL-C Primary Target Very high risk Documented CVD, previous AMI, ACS, coronary or other arterial revascularization, stroke, TIA, aortic aneurysm, PAD, DM with target organ damage (such as proteinuria or with a major RF such as smoking or marked hypercholesterolemia or marked hypertension), severe CKD (GFR <30mL/min/1.73m 2 ), or a calculated 10 year risk SCORE 10% <70mg/dL or 50% reduction from baseline between mg/dl High risk Markedly elevated single risk factors such as familial dyslipidemia and severe hypertension, most other people with DM, moderate CKD (GFR 30-59mL/min/ ) or a calculated SCORE 5% and <10% for 10 year risk of fatal CVD <100mg/dL or 50% reduction from baseline between mg/dl Moderate risk SCORE is 1% and <5% at 10 years, many middleaged subjects <115mg/dL
45 증례 2 : 다음치료는? rosuva20 M 45 NSTEMI, PCI T-Chol TG HDL-C LDL-C
46 증례 3 : 치료는? F 68 STEMI, PCI, DM T-Chol 165 TG 93 HDL-C 38 LDL-C 유럽치료지침 LDL-C Primary Target Very high risk Documented CVD, previous AMI, ACS, coronary or other arterial revascularization, stroke, TIA, aortic aneurysm, PAD, DM with target organ damage (such as proteinuria or with a major RF such as smoking or marked hypercholesterolemia or marked hypertension), severe CKD (GFR <30mL/min/1.73m 2 ), or a calculated 10 year risk SCORE 10% <70mg/dL or 50% reduction from baseline between mg/dl High risk Markedly elevated single risk factors such as familial dyslipidemia and severe hypertension, most other people with DM, moderate CKD (GFR 30-59mL/min/ ) or a calculated SCORE 5% and <10% for 10 year risk of fatal CVD <100mg/dL or 50% reduction from baseline between mg/dl Moderate risk SCORE is 1% and <5% at 10 years, many middleaged subjects <115mg/dL
47 증례 3 : 다음치료는? rosuva10 rosuva10 omega omega F 68 STEMI, PCI, DM T-Chol TG HDL-C LDL-C rosuva10 feno rosuva10 rosuva20 feno /ezetimi ?
48 증례 4 : 치료는? F 43 UA --> PCI T-Chol 520 HT DM TG 152 familial HC HDL-C 36 LDL-C 유럽치료지침 LDL-C Primary Target Very high risk Documented CVD, previous AMI, ACS, coronary or other arterial revascularization, stroke, TIA, aortic aneurysm, PAD, DM with target organ damage (such as proteinuria or with a major RF such as smoking or marked hypercholesterolemia or marked hypertension), severe CKD (GFR <30mL/min/1.73m 2 ), or a calculated 10 year risk SCORE 10% <70mg/dL or 50% reduction from baseline between mg/dl High risk Markedly elevated single risk factors such as familial dyslipidemia and severe hypertension, most other people with DM, moderate CKD (GFR 30-59mL/min/ ) or a calculated SCORE 5% and <10% for 10 year risk of fatal CVD <100mg/dL or 50% reduction from baseline between mg/dl Moderate risk SCORE is 1% and <5% at 10 years, many middleaged subjects <115mg/dL
49 증례 4 : 다음치료는? rosuva20 rosuva20 /ezetimi /ezetimi F 43 UA --> PCI T-Chol HT DM TG familial HC HDL-C LDL-C
50 증례 5 : 치료는? F 61 HT, FHx of CHD T-Chol yr risk 4.6% TG 177 SCORE 1-2% HDL-C 54 LDL-C 139 Atorva 유럽치료지침 LDL-C Primary Target Very high risk Documented CVD, previous AMI, ACS, coronary or other arterial revascularization, stroke, TIA, aortic aneurysm, PAD, DM with target organ damage (such as proteinuria or with a major RF such as smoking or marked hypercholesterolemia or marked hypertension), severe CKD (GFR <30mL/min/1.73m 2 ), or a calculated 10 year risk SCORE 10% <70mg/dL or 50% reduction from baseline between mg/dl High risk Markedly elevated single risk factors such as familial dyslipidemia and severe hypertension, most other people with DM, moderate CKD (GFR 30-59mL/min/ ) or a calculated SCORE 5% and <10% for 10 year risk of fatal CVD <100mg/dL or 50% reduction from baseline between mg/dl Moderate risk SCORE is 1% and <5% at 10 years, many middleaged subjects <115mg/dL
51 증례 6 : 치료는? M 61 no risk factor T-Chol yr risk 8.2% TG 114 SCORE 2% HDL-C 60 LDL-C 148 Atorva 유럽치료지침 LDL-C Primary Target Very high risk Documented CVD, previous AMI, ACS, coronary or other arterial revascularization, stroke, TIA, aortic aneurysm, PAD, DM with target organ damage (such as proteinuria or with a major RF such as smoking or marked hypercholesterolemia or marked hypertension), severe CKD (GFR <30mL/min/1.73m 2 ), or a calculated 10 year risk SCORE 10% <70mg/dL or 50% reduction from baseline between mg/dl High risk Markedly elevated single risk factors such as familial dyslipidemia and severe hypertension, most other people with DM, moderate CKD (GFR 30-59mL/min/ ) or a calculated SCORE 5% and <10% for 10 year risk of fatal CVD <100mg/dL or 50% reduction from baseline between mg/dl Moderate risk SCORE is 1% and <5% at 10 years, many middleaged subjects <115mg/dL
52 경청해주셔서감사합니다.
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Journal of Educational Innovation Research 2017, Vol. 27, No. 2, pp DOI: : Researc
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Comparison of Laparoscopy and Exploration in the Distal Pancreatectomy BACKGROUND: To determine the benefits of laparoscopic surgery compared with exploration, the clinical outcomes of open and laparoscopic
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저작자표시 - 비영리 - 동일조건변경허락 2.0 대한민국 이용자는아래의조건을따르는경우에한하여자유롭게 이저작물을복제, 배포, 전송, 전시, 공연및방송할수있습니다. 이차적저작물을작성할수있습니다. 다음과같은조건을따라야합니다 : 저작자표시. 귀하는원저작자를표시하여야합니다. 비
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Abstract Background : Most hospitalized children will experience physical pain as well as psychological distress. Painful procedure can increase anxie
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Purpose: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding
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Proposed Korean guideline for the diagnosis of BPH Hyun Woo Kim The Catholic University of Korea BPH Guideline AHCPR guideline on BPH (1994) AUA guideline on BPH (2003) EAU guideline on BPH (2004) International
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Sang Jun Kim, MD, PhD Application of 3D Printing in the Orthotic Fields Hallux Valgus, Charcot Marie Tooth, ADL Kit, Foot Insole, Wrist Pain, Foot Drop Development of Automated Program for Ankle Foot Orthosis
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Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar
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National Heart, Lung, and Blood Institute National High Blood Pressure Education Program 1997JNC 6, 1999WHO/ISH Why JNC 7? 50, SBPDBP 115/75 mmhg, 20 / 10 mmhg 2. 55 90%. SBP 120 139 mmhg DBP 80 89 mmhg
충북의대학술지 Chungbuk Med. J. Vol. 27. No. 1. 1~ Charcot-Marie-Tooth Disease 환자의마취 : 증례보고 신일동 1, 이진희 1, 박상희 1,2 * 책임저자 : 박상희, 충북청주시서원구충대로 1 번지, 충북대학교
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뇌혈관질환응급대응, 치료역량및관리체계 강화방안 뇌혈관분과이수주 을지대학교병원뇌졸중학회정책이사 허혈성뇌졸중 7.2% 출혈성뇌졸중 1.8% 75% 2015 (Hong KS et al. J Stroke 2013;15:2-20) Severance Stroke Center 심뇌혈관질환의예방및관리에관한법 권역심뇌혈관질환센터지정 뇌졸중적정성평가 뇌졸중 치료시스템 뇌졸중집중치료실인증
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