NGHIEN CUdJ TAN SUAT ROI LOAN TJ TG/HDL Of BENH NHAN BENH MACH VANH
Nguyin Cuu Loi*
T O M TAT
Dat van de: Ki'ch thUdc hat LDL la yeu td quyet djnh kha nang gay xd vu'a. Cd the dU doan miic LDL nhd va dam dac qua ti TG/HDL. Muc tieu ciia de tai la tim hieu tan suat tang TG/HOL d benh nhan benh mach vanh.
Doi tu'dng va phu'dng phap nahien eu'u:
nghien ciiu md ta cat ngang cac benh nhan benh mach vanh dUdc chan doan lan dau tien (xac djnh chan doan bang chup mach vanh chgn Igc).
Cac thdng sd nghien ciTu: TC, TG, HDL-C, LDL-C, non HDL-C va ti TG/HDL.
Ket qua: cd 292 benh nhan benh mach vanh dUdc chgn nghien ciiu, gdm 184 nam va 108 nd, tudi trung binh 65,57±11,26 (nam: 64,04±11,59;
nd: 68,19±10,20). SU hien dien ciia cac mau rdi loan lipid mau dUdc ghi nhan nhU sau: TC cao hdn 240mg/dl (6,2mM/l) trong 15,75% (nam:
11,41%; nu': 23,15%), TG cao hdn 200mg/dl (2.26mM/l) trong 40,07% (nam: 35,33%; nd:
48,15%), LDL-C cao hdn lOOmg/dl (2.6mM/l) trong 55,14% (nam: 52,72%; nii: 59,25%), HDL-C thap hdn 40mg/dl (ImM/l) trong 45,21%
(nam: 52,72%; nd: 32,41%), nonHDL-C cao hdn 130mg/dl (3.36mM/l) trong 64,38% (nam:
58,70%; nu': 70,07%), ti TG/HDL (mM/l) Idn hdn 1,8 trong 48,29% (nam: 46,20%; nO': 51,85%), ti TG/HDL (mg/dl) Idn hdn 3 trong 66,44% (nam:
65,76%; nCi: 67,59%).
Kit luan: ngoai LDL-C tang, nonHDL-C va ti TG/HDL cao cung hien dien trong mdt sd Idn cac benh nhan benh mach vanh. Do dd, trong dieu tri can lUu tam den thanh phan TG va HDL nhU la muc tieu dieu tri cua benh mach vanh.
ABSTRACTS
PREVALENCE OF INCREASED TG/HDL RATIO IN PATIENTS WITH CORONARY ARTERY DISEASE Background: Size of LDL-C particles is the principle factor for atherogenicity. Level of small dense LDL-C may be predicted by TG/HDL ratio.
Purpose of this study was to estimate the prevalence of high TG/HDL ratio in patients with coronar/ artery disease.
Method and materials: retrospective and registry study on consecutive first diagnosed CAD patients during one year at a cardiovascular center. Diagnosis of CAD was confirmed by coronary angiography. Studied variants included: TC, TG, HDL-C, LDL-C, non-HDL-C and TG/HDL ratio.
Results: 292 patients were enrolled, included 184 male (%) and 108 female (%) patients. Mean age was 65.57±11.26 (male:
64.04±11.59; female: 68.19±10.20). Models of dyslipidemia in these patients were: TC >
240mg/dl (6.2mM/l) in 15.75% (male: 11.41%;
female: 23.15%), TG > 200mg/dl (2.26mM/l) in 40.07% (male: 35.33%; female: 48.15%), LDL-C
> lOOmg/dl (2.6mM/l) in 55.14% (male:
52.72%; female: 59.26%), HDL-C < 40mg/dl (ImM/l) in 4 5 . 2 1 % (male: 52.72%; female:
32.41%), nonHDL-C > 130mg/dl (3.36mM/l) in 64.38% (male: 58.70%; female: 70.07%), TG/HDL (mM/l) ratio > 1,8 in 48.29% (male:
45.20%; female: 51.85%), TG/HDL (mg/dl) ratio
> 3 in 66.44% (male: 65.76%; female: 67.59%).
Conclusions: High LDL-C was not frequently seen in our CAD patients. Low HDL-C and/or high TG should be considered in secondary therapy.
• Tnmg ldm Tim mgch. Benh vien Tnmg U'ang Hui
I. OAT VAN OE
Tang cholesterol mau da dugc xem la yeu td nguy ca chinh ciia benh mach vanh do xa vua, trong dd LDL-C la thanh phin dang quan tam nhat, va la muc tieu chinh trong digu tri theo ATPIII (NCEP) [1]. Tuy nhien, cac nghien cuu gan day da cho thiy kich thudc ciia hat LDL-C (kich thudc nhd va dam dac) la yeu td quyet dinh kha nang gay xo vQa. Cac hat LDL-C nhd lai khdng the dugc dinh lugng true tiep ma chi cd th6 danh gia gian tidp qua ti TG/HDL [2][3].
Do dd, de tai nay dugc thuc hien nham khao sat tan suat ciia cac rdi loan TG/HDL d benh nhan benh mach vanh.
II. OOI TUONG VA PHUONG PHAP NGHIEN CCfU 1. Doi tuong nghien cmi: nhiing benh nhan dugc chan doan benh mach vanh lan dau tien, nhap vien tai Trung tam Tim mach - Benh vien Trung LTong Hue tu thang 6 nam 2009 den thang 6 nam 2010. Chan doan xac dinh benh mach vanh bang chup mach vanh chgn lgc, vdi ton thuang hep ldng mach tdi thieu 30%.
2. Tieu chuan loai trii" benh mach vanh da dugc chan doan trude dd va dang dugc dieu tri.
3. Phuong phap nghien ciiru: nghien cuu quan sat, hdi cuu theo hd sa (registry study).
Xir ly sd lieu bang chuong trinh Excel va Medcalc.
III. KET QUA NGHIEN CCfU
Tir thang 6/2009 din thang 7/2010 cd 292 benh nhan benh mach vanh du tieu chuan chgn benh dugc nghien cim, gdm 184 nam (63,01%) va 108 nir (376,99%), tudi trung binh chung la 65,57±11,26; khdng khac biet cd y nghia giiia nam va nir (nam:
64,04±11,59; nu 68,19±10,20). Tuy nhien, trong nhdm nam gidi cd nhieu benh nhan dudi 50 tudi ban nii (7,61% so vdi 3,75%, 95% CI = -1,386 to 9,106; p = 0,2844) va tudi nhd nhat thap hon nH gidi (33 tudi so vdi 47 tudi). TC va TG trong nhdm benh nhan nir cao ban nhdm benh nam mdt each cd y nghla (p<0,05) nhung HDL ciing cao ban (p<0,001).
Ti le nonHDL-C trong nhdm benh nhan nir Cling cao ban (p<0,05). Tuy nhien, ti TG/HDL tinh theo ca hai don vi (mM/l va mg/dl) tuong duong nhau giiia hai nhdm {Bdng 1).
Bdng 1: Cac thdng sd ve tudi va lipid mau cua cac nhdm Thong so
n Tudi Tud'i nhd nhat
Tud'i Idn nhat DUdi 50 tud'i
TC TG HDL-C
LDL-C nonHDLpC (mM/l) Non HDL-C (mq/dl)
TG/HDL-C (mM/l) TG/HDL-C (mq/dl)
Chung 292 65,57±11,26
33 87 17 5,01±1,22 2,29±1,40 1,13±0,28 2,92±1,11 3,88±1,17 150,17±45,40
2,20±1,51 5,04±3,46
NamCD 184 (63,01%)
64,04±11,59 33 87 14 (7,61%)
4,85±1,18 2,16±1,34 1,08±0,27 2,85±1,04 3,77±1,16 145,61±44,77
2,13±1,49 4,89±3,42
nghien cuu NQH) 108 (36,99%)
68,19±10,20 47 87 3 (3,75%) 5,28±1,24 2,52±1,46 1,20±0,29 3,06±1,20 4,08±1,18 157,94±45,60
2,31±1,54 5,29±3,53
P(l&2) 0,0016
0,0034 0,0349 0,0006 0,1227 0,0257 0,0257 0,3474 0,3474
Khi khao sat tan suat ciia cac mau rdi loan lipid mau hien dien d benh nhan benh mach vanh thi tang TC tren miic khuyen cao (240mg/dl # 6.2mM/l) cd tin suit thap nhat (15,75%), da so d nu gidi (23,15% so vdi 11,41% d nam gidi; 95% CI = 2,554 - 20,926; p = 0,0127). Neu xet rieng timg thanh phin lipid mau thi ti le hien dien ciing khdng cao. Tang TG tren 200mg/dl chi gap trong 40% trudng hgp chung va thudng gap d nil ban nam (48,15% so vdi 35,33%; 95%
CI = 1,136 to 24,504; p=0,0419). Tang LDL- C la yeu td nguy co dugc nhac den nhieu
nhat ciing chi hien dien trong 55,14% trudno hgp vdi tan suat tucmg tu d nam va nir (52,72% va 59,26%, p=0,3356); hoac HDL nhu mgt yeu td bao ve ciing giam trong 45,21%) vdi tan suat cao ban d nam (52,72%
so vdi 32,41%; 95% CI = 8,910 to 31,710;
p=0,0012). :^-; 9k:
Khi phan tfch cac mau rdi loan lipid mau phdi hgp thdng qua cac chi sd nonHDL-C va ti TG/HDL thi tan suat cd y nghia thong ke nhieu nhat (64,38%) ddi vdi nonHDL va 66,44% ddi vdi TG/HDL) vdi tan suit tuong duong nhau d nam gidi va nir gidi {Bang 2).
Bdng 2: So sanh tan suat ciia cac mau rdi loan lipid mau giira hai nhdm benh nhan nam vanu:
Mau r61 loan lipid
TC > 6.2 mM/l (240mg/dl) TG > 2.26mM/l (200mq/dl) LDL-C>2,6mM/l (lOOmq/dl)
NonHDL-C>3,36mM/l (130mq/dl) HDL-C<lmM/l(40mq/dl)
TG/HDL(mM/l)>l,33 TG/HDL(mg/dl)>3
C h u n g ( 2 9 2 ) n
46 117 161 188
132 194
o/o 15,75%
40,07%
55,14%
64,38%
45,21%
66,44%
Nam n 21 65 97 108
97 121
( 1 8 4 )
% ( 1 ) 11,41%
35,33%
52,72%
58,70%
52,72%
65,76%
N u ' d O S ) n
25 52 64 80
35 73
% ( 2 ) 23,15%
48,15%%
59,26%
70,07%
32,41%
67,59%
P {1&2) 0,0127 0,0419 0,3356 0,0693
0,0012 0,8483
Trong nhdm benh nhan cd LDL-C d mirc an toan (tiic la thip ban lOOmg/dl hay lmM/1 theo khuyen cao) thi cd mdt ti le dang ke cac miu rdi loan lipid cd lien quan cac cholesterol nonHDL-C hay LDL hat nhd (TG/HDL). Cu thd la van cd 30,54% trong so benh nhan nay co nonHDL tang, thudng gap d nii ban nam (50% so vdi 22,99% tuang iing; 95% CI = 9,792 - 44.228; p=0,0034). Dac biet ti le TG/HDL hien dien phd bien ban (len ddn 68,70% khi tinh bing dan vj mg/dl) va cd xu hudng thudng gap ban d nil' (81,82% so vdi 65,52%; 95% Cl =
1,147 to 31.453; p = 0,0822) {Bdng 3).
Bdng 3: Tan suat cac mau rdi loan lipid khac trong nhdm benh nhan cd LDL-C d mirc an toan(<100mg/dl)
M I U roi loan lipid
nonHDL > 130mq/dl TG/HDL(mM/l)>l,33
TG/HDL(mq/dl)>3
Ca hai gidi ( 1 3 1 ) n
40 90
o/o 30,54%
68,70%
Nam ( 8 7 ) n
20 57
% ( 1 ) 22,99%
65,52%
NO" ( 4 4 ) n
22 36
o/o ( 2 ) 50%
81,82%
P (1&2)
0,0034 0,0822
IV. BAN LUAN
LDL-C la muc tieu di§u tri chinh theo khuyen cao ciia Hdi Tim mach Hoa Ky (AHA) [4], Hiep hdi Tim mach chau Au (ESC) [5] va Hdi Tim mach Viet Nam [6]
trong dieu tri du phdng thu' phat benh mach vanh. Cac thanh td khac cua lipid mau ciing dugc xet den nhu TC, hoac HDL va TG.
Tuy nhien, gan day vai trd gay xo vda ciia LDL-C kich thudc nhd va mat do cao da dugc chu y va khao sat trong nhieu nghien ciiu. Mdt sd nghien ciru da tien hanh dinh lugng true tiep LDL oxy hda (ox-LDL) va cho thay tan suat tang ox-LDL len den 76%) d benh nhan benh mach vanh [7]. Tang nonHDL-C va ti TG/HDL ciing hien dien vdi tan suat cao d nhiing benh nhan cd hdi chung chuyen hda hay DTD type 2, dac biet la d nir gidi [8]. Diem cut-off cua cac thdng sd nay Cling da dugc xac dinh qua cac nghien cim Idn (130mg ddi vdi non HDL; 1,33 ddi vdi ti TG/HDL tinh theo don vi mM/l [2] va 3 ddi vdi ti TG/HDL tinh theo don vi mg/dl [9]. Ti TG/HDL >1,33 hien dien trong 90% cac trudng hgp cd LDL hat nhd va mat do cao.
Ngoai ra, ti TG/HDL lai cd vai trd tien lugng dac biet d nhimg benh nhan khdng cd hdi chimg chuyen hda va d nam gidi thi khdng tuong quan vdi BMI [10].
Hon nira, ngay trong nhdm benh nhan cd LDL-C d muc an toan <100mg/dl (tiic la mirc LDL tdi uu dat dugc khi dieu tri) nhu quan niem trude day thi cung cd hon mdt nira trudng hgp cd rdi loan HDL va TG ggi y nong do cao LDL nhd va mat do cao (30.54% vdi non HDL va 68,70% vdi ti TG/HDL), dac biet la d nil gidi (50% - 81,82%).
d benh nhan dai thao dudng type 2, mac dau HDL trong gidi ban binh thudng va TG
< 2,3niM/l iibmig ti sd TG/HDL da cho thiy
mdi tuong quan vdi kich thudc cua hat LDL- C, mdt yeu td quyet dinh cho kha nang gay xa viia ciia LDL-C [8]. Didm cut-off 1,33 da dugc de nghi la diem phan biet cho kich thudc hat LDL-C (cang nlid khi ti TG/HDL cang ldn) va ddng nghia vdi nguy ca xo -viia cao hon [8]. Nghien cim ACCORD (phan nhanh lipid) dugc tien hanh tren ca sd cac nhan dinh nhu tren da chimg minh hieu qua ciia dieu tri phdi hgp fibrate va statin trong viec lam giam cac bien chiing mach mau ldn d nhdm benh dai thao dudng type 2. Nhu vay, trong khi chua cd mdt phuang phap dinh gia khang insulin cd do chinh xac cao va dinh lugng true tiep ndng do LDL hat nhd thi viec tien lugng nguy co xo vira bing ti TG/HDL cd gia tri thuc tien rit cao [2].
V. KET LUAN
Cd nhieu thanh td cua lipid mau cd vai trd quan trgng trong benh sinh xo vila ddng mach (HDL, LDL, VLDL, IDL, TG). Hien chua cd mdt thdng ke ve tan suit rdi loan ciia timg thanh td nay d benh nhan benh mach vanh d nudc ta. Tuy vay, ngoai LDL la thanh td dugc chu y nhieu nhat trong cac khuyen cao thi viec ndng do LDL hat nhd cd tinh sinh xa viia rat cao cd the dugc du doan thdng qua ti le TG/HDL.
TAI UEU THAM KHAO
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2. Laurie Barclay. Triglycerides and TG-HDL Ratio Help Identify Insulin Resistance in
Overvseight Patients. Ann Intern Med. 7.
2003;139:802-809.
Lamarche B, Lemieux I, Despres JP: The small dense phenotype and the risk of coronar}' heart disease: epidemiology, pathoph\siology and therapeutic aspects. 8.
Diabete Metab 25:199-211,1999
Sidney C.Smith. Lipid management - Secondary prevention for patients with coronar> and other atherosclerotic vascular disease. Inj_ The AHA guidelines and scientific statements handbook. Pub: Wiley- Blaclovell 2009: 109-110.
Ian Graham and task force members of ESC. Cardiovascular prevention in clinical practice. Iin ESC guidelines desk reference.
Pub: Wolters-Kluwer 2007; 3-13.
Dang Van Phuoc va tieu ban soan thao khuyen cao. Khuyen cao 2008 cua Hgi Tim mach hoc Viet Nam've chan doan va dieu trj roi loan lipid mau. Trong: Khuyen cao 2008 ve cac benh ly tim mach & chuyen hoa. Nhd xudt ban Yhoc 2008. Tr. 476-493.
Joya Ghosh, T.K. Mishra, Y.N. Rao, S.K.
Aggarwal. Oxidised LDL, HDL cholesterol.
LDL cholesterol levels in patients of coronary arter>' disease. Indian Journal of Clinical Biochemistry, 2006, 21 (1) 181-184 R. Boizel, P.Y. Benhamou, B. Lardy et als.
Ratio of Triglycerides to HDL cholesterol is an indicator of LDL particle size in patients with tj'pe 2 diabetes and normal HDL cholesterol levels. Diabetes Care 2000;
23:1679-1685.
Ferrara, L; Russo, B; Di Fronzo, V;
Gente, R; Staiano, L; Marotta, T. High TG/HDL ratio helps in the evaluation of cardiovascular risk of hypertensive patients without metabolic syndrome. Journal of Hypertension: June 2010 - Volume 28 - Issue - p e 5 6 9 .
10. Cordero A, Andre E, Ordonez B et als.
Usefulness of triglycerides-to-high-density lipoprotein cholesterol ratio for predicting the first coronary event in men. Am J Cardiol 2009 Nov 15; 104(10); 1393-7.
9.
