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Рекомендации для врачей по ведению пациентов с дислипидемией и атеросклерозом

Под редакцией профессора А.В. Сусекова

Вступительное слово главного редактора

Перед вами вторая редакция «Рекомендаций для врачей по ведению пациентов с дислипидемией и атеросклерозом». Первая редакция вышла в 2014 году на основе книги «Дислипидемия», написанной канадскими учеными-медиками Сарой МакФерсон и Жане Мновик Кондейевски.

Развернуть За последние годы достигнут значительный прогресс в диагностике и лечении больных с нарушениями липидного обмена. Опубликованы результаты новых клинических исследований (IMPROVE-IT, FOURIER, ODYSSEY OUTCOMES), в которых дополнительное снижение уровня холестерина в комбинированной терапии (статины+) приводило к дальнейшему снижению сердечно-сосудистого риска. Это послужило основанием для снижения целевых уровней ЛНП у всех категорий больных, обновлены десятки липидных рекомендаций по всему миру. Как следствие, комбинированная терапия с целью снижения уровня ХС-ЛНП прочно входит в стандарты лечения больных высокого сердечно-сосудистого риска.

Вместе с тем терапия статинами и достижение целевых уровней липидов у большинства больных очень высокого сердечно-сосудистого риска в нашей стране пока далеки от оптимальных показателей. Интенсивную терапию статинами получают 2–3% пациентов в РФ, в лучшем случае лишь каждый 10-й больной достигает целевых уровней ХС-ЛНП. Продолжительность такого лечения – не более 6 месяцев. Большое количество детей и взрослых с семейной ГЛП в нашей стране не диагностировано, менее 1% получают адекватную терапию.

В этой редакции Рекомендаций я оставил значительную часть базового материала, касающегося основ клинической липидологии, общего представления о липидах, физиологии, патофизиологии дислипидемий и т. д.

Новые положения, внесенные мною в эту версию рекомендаций, касаются:

  • обновления научных данных о жирных кислотах, растительных стеролах, апоВ, Лп(а), основных стадиях атерогенеза; новых данных по диагностике гипобеталипопротеинемии, ситостеролемии, дефицита ЛХАТ, болезни Танжера и т. д.;
  • обзора ключевых международных рекомендаций, консенсусов;
  • новых алгоритмов по управлению семейной ГЛП у детей и взрослых;
  • рекомендаций EAS по выбору продуктов питания для снижения холестерина; «диеты спасения» для больных с выраженной гипертриглицеридемией;
  • оптимизации статинотерапии в первичной/вторичной профилактике;
  • простых алгоритмов управления статиновой миопатией и гиперферментемией с учетом уровня билирубина;
  • классификации и дифференциальной диагностики гипертриглицеридемий;
  • результатов завершенных клинических исследований гиполипидемических средств, зарегистрированных в РФ;
  • алгоритмов комбинированной терапии с учетом исходных показателей ЛНП;
  • мини-обзора, посвященного новым гиполипидемическим препаратам.

Для подготовки редакторских комментариев был использован материал 89 системных литературных обзоров, 33 международных рекомендаций и консенсусов, 14 регистров и 157 клинических исследований. Список литературы представлен 386 источниками.

Хочется верить, что новая версия Рекомендаций будет полезным руководством по клинической липидологии для студентов, аспирантов, врачей разных специальностей и в конечном итоге будет способствовать оптимизации диагностики/лечения дислипидемий.

С уважением,
профессор А.В. Сусеков

Содержание

19.04.2024
Глава первая
Дислипидемия – общее название группы заболеваний, характеризующихся изменением содержания липидов или липопротеинов в плазме крови или их качества (Marais, 2013).

19.04.2024
Глава вторая
Метаболизм липидов включает в себя поглощение липидов, синтез липидов (липогенез) и окисление ЖК (липолиз) для выработки энергии. Пищевые липиды всасываются пищеварительной системой, а накопление...
19.04.2024
Глава третья
Нарушение обмена липидов лежит в основе патогенеза дислипидемий. Дислипидемия – это группа заболеваний, имеющих многофакторную этиологию. Эта группа включает гиперлипидемии, гиперлипопротеинемии,...
19.04.2024
Глава четвёртая
Гиперлипидемии (и гиперлипопротеинемии) – это группа заболеваний, которые могут быть диагностированы при рутинной оценке липидного профиля. Эти нарушения характеризуются патологическим...
19.04.2024
Глава пятая
Как правило, гиполипидемии и болезни нарушенного транспорта ХС выявляются сразу после рождения или в раннем детстве. Эти состояния включают некоторые формы семейных гипохолестеринемий, характеризующиеся...
19.04.2024
Глава шестая
Исследователи сфокусированы на изучении генетических, эпигенетических и диетических факторов, влияющих на метаболизм липидов. Эти факторы могут быть биомаркерами, указывающими на риск сердечно-сосудистых...


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Заключение редактора

Уважаемые коллеги!

Клиническая липидология – весьма сложная, но интересная медицинская наука, которая касается здоровья миллионов наших пациентов и внимания врачей самых разных специальностей – кардиологов, терапевтов, эндокринологов, гастроэнтерологов, педиатров, генетиков и др.

Развернуть Статины были и остаются основным классом препаратов для профилактики и лечения атеросклероза, во всем мире их принимают почти полмиллиарда человек. К сожалению, в нашей стране эта терапия, хотя и стала доступнее для большинства больных, все равно пока малоэффективна (низкие дозы, страхи и предрассудки по безопасности и т. д). По-прежнему, в повседневной практике актуальны задачи назначения адекватных доз статинов, повышения приверженности лечению, внедрения в практику новых лекарственных препаратов. Комбинированная липидснижающая терапия расширила наши возможности в контроле липидов у тяжелых пациентов очень высокого СС риска и больных с семейной гиперхолестеринемией. В этой книге можно найти экстракт современных международных и российских клинических рекомендаций и оригинальных статей, охватывающих разнообразные аспекты диагностики и лечения нарушений липидного обмена.

Очень надеюсь, что эти Рекомендации окажутся полезным справочным пособием и надежным помощником при решении сложных клинических задач.

До новых встреч!

С уважением,
А.В. Сусеков

Ссылки на источники

Развернуть

Аббревиатуры

Развернуть АВА – аденовирус-ассоциированный

АГ – артериальная гипертензия

АД – артериальное давление

АКШ – аортокоронарное шунтирование

АТФ – аденозинтрифосфат

БВ – болезнь Вольмана

БК – Бемпедоевая кислота

БНЭХ – болезнь накопления эфиров холестерина

БПЭХ – белок, переносящий эфиры холестерина

БТ – болезнь Танжера

ВОЗ – Всемирная организация здравоохранения

ВПН – верхний предел нормы

ГА – гипоальфалипопротеинемия

ГАЛП – гиперальфалипопротеинемия

ГЭБ – гематоэнцефалический барьер

ДЛКЛ – дефицит лизосомной кислой липазы

ЖК – жирные кислоты

ЖКТ – желудочно-кишечный тракт

ИБС – ишемическая болезнь сердца

ИМ – инфаркт миокарда

КФК – креатинфосфокиназа

ЛКЛ – лизосомальная кислая липаза

ЛПВП – липопротеины высокой плотности

ЛПЛ – липопротеинлипаза

ЛПНП – липопротеины низкой плотности

ЛПОНП – липопротеины очень низкой плотности

ЛППП – липопротеины промежуточной плотности

ЛХАТ – дефицит лецитинхолестерол ацилтрансферазы

МПБ – микросомальный переносящий белок

МС – метаболический синдром

ОКС – острый коронарный синдром

ОХС – общий холестерин

САМ – статин-ассоциированная миотоксичность

САМС – статин-ассоциированные мышечные симптомы

СГЛП – семейная гиперлипидемия

СГХС – семейная гиперхолестеринемия

СД – сахарный диабет

СКХС – семейная комбинированная гиперхолестеринемия

ССЗ – сердечно-сосудистые заболевания

СРБ – С-реактивный белок

ТАГ – триацилглицеролы

ТГ – триглицериды

ТИА – транзиторная ишемическая атака

ТИМ – толщина комплекса интима-медиа

тПН – терминальная почечная недостаточность

ТТГ – тиреотропный гормон

УЗИ – ультразвуковое исследование

ХПН – хроническая почечная недостаточность

ХС – холестерин

ХС-ЛПВП – холестерин липопротеинов высокой плотности

ХС-ЛПНП – холестерин липопротеинов низкой плотности

ХС-неЛПВП – холестерин не липопротеинов высокой плотности

ЦНС – центральная нервная система

ЭР – эндоплазматический ретикулум

ЭЛ – эндотелиальная липаза


Уровни доказательности в рекомендациях

Градации достоверности рекомендаций Уровень убедительности доказательств Вид исследования
А Систематический обзор рандомизированных контролируемых исследований (испытаний), РКИ
1B Отдельное рандомизированное контролируемое исследование
В 2A Систематический обзор исследований «случай – контроль»
2B Отдельное когортное исследование
3A Систематический обзор исследований «случай – контроль»
3B Отдельные исследования «случай – контроль»
С 4 Исследование серии случаев
Д 5 Мнение эксперта, не подвергавшееся критической оценке либо основанное на физиологии, результатах пробного исследования или на «основных принципах»

Книга предназначена для неврологов, терапевтов, анестезиологов, психиатров, психологов и других медицинских работников, участвующих в лечении пациентов с дислипидемией и атеросклерозом.  

Данное издание является объектом авторского права.
Все права защищены относительно издания целиком и его составляющих, т. е. перевода, переиздания, воспроизведения иллюстраций, цитирования, воспроизведения на микрофильмах или любым другим способом и хранения в базе данных.

© Anejo Health Communications