中国血脂管理指南(基层版2024年)

摘要: 低密度脂蛋白胆固醇(LDL-C)是动脉粥样硬化性心血管疾病(ASCVD)的致病性危险因素。近几十年来，中国人群的血脂异常患病率不断升高，血脂管理刻不容缓，在基层开展血脂规范管理尤为重要。《中国血脂管理指南(基层版2024年)》简明地推荐LDL-C作为血脂干预的首要靶点，以ASCVD危险分层确定其目标值；推荐在生活方式干预的基础上，以中等强度他汀类药物作为起始药物治疗，必要时联用胆固醇吸收抑制剂和(或)前蛋白转化酶枯草溶菌素9抑制剂的达标策略；并就常见特殊人群的血脂管理策略进行了推荐。本指南旨在为基层医生开展血脂管理提供指导，全面提升基层医生的血脂管理水平，推进ASCVD的一级和二级预防工作。
- 动脉粥样硬化 /
- 心血管疾病 /
- 血脂管理 /
- 低密度脂蛋白胆固醇 /
- 基层
Abstract: Low-density lipoprotein cholesterol (LDL-C) is a pathogenic risk factor for atherosclerotic cardiovascular disease (ASCVD). In recent decades, the prevalence of dyslipidemia in the Chinese population increases continuously, it is urgent to improve blood lipid management in China. It is particularly important to carry out standardized blood lipid management at primary healthcare institutions. The Chinese guideline for lipid management (primary care version 2024) concisely recommends that LDL-C should be the preferred intervention target in lipid management, and the target values of LDL-C should be determined based on ASCVD risk stratification. The present guideline recommends to use moderate-intensity statins at the beginning of treatment on the basis of lifestyle intervention. If the LDL-C target level can not be reached, other lipid-lowering drugs like cholesterol absorption inhibitors and (or) proprotein convertase subtilisin/kexin type 9 inhibitors should be jointly used for the purpose of reaching the target value. The present guideline also provides blood lipid management strategies for special populations. We aim to provide guidance for primary healthcare professionals to carry out blood lipid management, and comprehensively improve their ability on blood lipid management, and thereby improve the primary and secondary prevention of ASCVD in China.
- atherosclerosis /
- cardiovascular disease /
- blood lipid management /
- low-density lipoprotein cholesterol /
- primary healthcare institution

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图 1 中国成年人ASCVD总体风险评估流程图

Figure 1. The risk assessment flow chart of ASCVD in Chinese adults

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图 2 降脂策略流程图

Figure 2. Flow chart of lipid-lowering strategy

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图 3 降脂过程中的监测流程图

Figure 3. Monitoring flow chart of lipid-lowering treatment

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图 4 他汀类药物不良反应处理原则

Figure 4. Management of adverse reactions to statins

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表 1 中国ASCVD一级预防低危人群非糖尿病患者主要血脂指标的参考标准

Table 1. Reference values of blood lipids for the primary prevention of ASCVD in low-risk populations without diabetes mmol/L

分类	TC	LDL-C	HDL-C	TG	非HDL-C
理想水平	-	＜2.6	-	-	＜3.4
合适水平	＜5.2	＜3.4	-	＜1.7	＜4.1
边缘升高	≥5.2且＜6.2	≥3.4且＜4.1	-	≥1.7且＜2.3	≥4.1且＜4.9
升高	≥6.2	≥4.1	-	≥2.3	≥4.9
降低	-	-	＜1.0	-	-
注：表中所列数值是干预前空腹12 h测定的血脂水平。-：无。

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表 2 降脂靶点的目标值

Table 2. The goal attainment values of LDL-C

ASCVD风险等级	LDL-C推荐目标值
低危^a)	＜3.4 mmol/L^[5]
中、高危^a)	＜2.6 mmol/L^[6-7]
极高危	＜1.8 mmol/L且较基线降低幅度>50%^[8-10]
超高危	＜1.4 mmol/L且较基线降低幅度>50%^[8-10]
注：^a)合并糖尿病的ASCVD低、中、高危患者血脂目标参见“特定人群的血脂管理”糖尿病患者部分。

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表 3 血脂管理膳食治疗建议

Table 3. Recommendation of dietary therapy for lipid management

推荐建议
①限制油脂摄入总量，20~25 g/d。采用不饱和脂肪酸(植物油)替代饱和脂肪酸(动物油、棕榈油等)^[12]
②避免摄入反式脂肪酸(氢化植物油等)^[12]
③增加蔬菜和水果、全谷物、膳食纤维和鱼类的摄入
④ASCVD中危以上人群或合并高胆固醇血症患者应考虑控制膳食胆固醇摄入，＜300 mg/d^[13-14]

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表 4 降TG的药物治疗建议

Table 4. Recommendation of drugs for TG-lowering treatment

推荐建议
TG≥5.6 mmol/L时，可采用贝特类、ω-3脂肪酸或烟酸类药物治疗，以降低胰腺炎风险^[16]
ASCVD患者及高危人群接受中等剂量他汀类药物治疗后如TG≥2.3 mmol/L，应优先考虑给予大剂量IPE(2 g，2次/d)^[17-18]，其次可考虑给予其他ω-3脂肪酸^[17]或非诺贝特、苯扎贝特，以进一步降低ASCVD风险^[19-20]
注：IPE：二十碳五烯酸乙酯。

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表 5 他汀类药物降胆固醇强度

Table 5. The cholesterol reduction intensity of stains

降胆固醇强度	药物及其剂量
高强度(每日剂量可降低	阿托伐他汀40~80 mg
LDL-C ≥50%)	瑞舒伐他汀20 mg
中等强度(每日剂量可降	阿托伐他汀10~20 mg
低LDL-C 25%~＜50%)	瑞舒伐他汀5~10 mg
	氟伐他汀80 mg
	洛伐他汀40 mg
	匹伐他汀1~4 mg
	普伐他汀40 mg
	辛伐他汀20~40 mg
	血脂康1.2 g

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表 6 主要降TG的药物

Table 6. Main TG-lowering drugs

药物分类	剂量	不良反应
贝特类药物
非诺贝特片	0.1 g，3次/d	包括肝脏、肌肉和肾毒性等
微粒化非诺贝特	0.2 g，1次/d
非诺贝特缓释胶囊	0.25 g，1次/d
苯扎贝特	0.2 g，3次/d
苯扎贝特缓释片	0.4 g，1次/d
吉非贝齐	0.6 g，2次/d
ω-3脂肪酸
IPE	1~4 g/d	胃肠道反应，大剂量应用可能增加轻微出血、新发心房颤动风险
EPA+DHA	1~4 g/d	胃肠道反应，大剂量应用可能增加轻微出血、新发心房颤动风险
烟酸及其同类物
烟酸缓释片	0.375~1.000 g，1次/d	颜面潮红、皮肤瘙痒、皮疹、肝脏损害、高尿酸血症、高血糖、棘皮症和消化道不适等
阿昔莫司	0.25~0.50 g，2次/d	颜面潮红、皮肤瘙痒、皮疹、肝脏损害、高尿酸血症、高血糖、棘皮症和消化道不适等
注：IPE：二十碳五烯酸乙酯；EPA：二十碳五烯酸；DHA：二十二碳六烯酸。

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表 7 降脂药物的联合应用策略

Table 7. Combination of lipid-lowering drugs

联合应用策略^a)	适用情况	安全性关注点
他汀类药物+胆固醇吸收抑制剂	单药治疗后LDL-C不达标	常规监测
他汀类药物+PCSK9抑制剂	单药治疗后LDL-C不达标	常规监测
他汀类药物+胆固醇吸收抑制剂+PCSK9抑制剂	双联用药后LDL-C不达标	常规监测
他汀类药物+ω-3脂肪酸(IPE、EPA+DHA)或非诺贝特	LDL-C达标、TG 2.3~5.7 mmol/L	心房颤动、出血、肾功能
贝特类药物+ω-3脂肪酸(IPE、EPA+DHA)	单药治疗后TG≥5.7 mmol/L	常规监测
注：^a)联合应用策略中的他汀类药物均指中等强度他汀类药物(具体药物和剂量见表 5)。

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表 8 糖尿病患者血脂目标值建议

Table 8. Recommendation of target values of blood lipids in patients with diabetes

推荐建议
糖尿病合并ASCVD患者：LDL-C＜1.4 mmol/L^{[10, 21, 26]}，且降低幅度>50%
ASCVD风险为高危的糖尿病患者^a)：LDL-C＜1.8 mmol/L^[27]，且降低幅度>50%
ASCVD风险为低、中危的糖尿病患者：LDL-C＜2.6 mmol/L^[17]
糖尿病患者以非HDL-C为次要目标，目标值为相应的LDL-C目标值+0.8 mmol/L
注：^a)指年龄≥40岁的糖尿病患者，或者20~39岁糖尿病患者有≥3个危险因素(高血压、血脂异常、吸烟、肥胖、早发冠心病家族史)或合并靶器官损害(蛋白尿、肾功能损害、左心室肥厚或视网膜病变)或1型糖尿病病程≥20年。

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表 9 脑卒中患者的降脂治疗建议

Table 9. Recommendation of lipid-lowering treatment for stroke patients

推荐建议
对于单纯动脉粥样硬化性缺血性脑卒中或TIA患者，建议LDL-C＜1.8 mmol/L；非HDL-C＜2.6 mmol/L^[33]
对于动脉粥样硬化性缺血性脑卒中或TIA患者，推荐他汀类药物作为首选治疗^[33-34]
对于动脉粥样硬化性缺血性脑卒中或TIA患者，经他汀类药物治疗LDL-C不达标者可加用胆固醇吸收抑制剂^[21]
对于动脉粥样硬化性缺血性脑卒中或TIA患者，经他汀类药物+胆固醇吸收抑制剂治疗LDL-C不达标者可加用PCSK9抑制剂^{[10, 26]}
注：TIA：短暂性脑缺血发作。

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