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《柳叶刀》(The Lancet)发表的评论指出,近年来心血管疾病发病率的趋势总体稳定,但发生结构性变化,表现为急性冠状动脉综合征和卒中发病率持续下降,非动脉粥样硬化性疾病发病率保持稳定或上升。面对这种情况,相关从业者应重新审视当前的预防策略,制定更全面的一级预防战略,对心血管标志物展开研究,并针对新发现的危险因素展开研究。识别图中二维码或点击文末阅读原文,查阅原文。


过去50年,心血管疾病预防领域的进步常被称为公共卫生领域的重大成就之一。这些成就来源于人们对心血管疾病“无法避免”观念的突破与挑战,从而发现了可改变的危险因素,并采取系统的方法来预防危险因素暴露。自20世纪60年代以来,这些预防工作已经使全球许多地区的心血管疾病的过早死亡率和发病率大幅下降[1-3]。然而,在一些高收入国家,这一下降趋势似乎已停滞,甚至出现反转[3-6]。心血管疾病的发病率似乎也呈现类似趋势,即使排除了人口老龄化因素的影响,自 21世纪中期以来,心血管疾病的新发病例数也几乎没有变化[7]。 这些不利趋势的根本原因在于肥胖、糖尿病和慢性肾病发病率的上升[5]


一个较少被讨论的角度是,心血管疾病表现类型的变化可能会如何影响人群的总体疾病负担,进而影响心血管疾病的预防策略。


近期一系列大规模研究通过调查不同心血管疾病的长期趋势,为这一角度提出了新见解[7-14]。这些最新研究表明,心血管疾病发病率的总体稳定趋势掩盖了心血管疾病病例结构性变化急性冠状动脉综合征和卒中发病率持续下降[14-17]动脉粥样硬化性疾病(包括心律失常、心脏瓣膜病和静脉血栓栓塞)的发病率则保持稳定或有所上升[7-12]。由于这些新出现的趋势,传统上被视为最常见的心血管疾病(如冠心病和卒中),如今在心血管疾病总发病率中的占比已不足一半(如图所示)。相比之下,其他疾病则相对更为常见。例如,心房颤动或心房扑动已成为目前最常见的心血管问题,静脉血栓栓塞和心脏传导阻滞的发病率已与卒中或急性冠状动脉综合征的发病率大致相当[7][9][14][16][18]


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其中一些疾病发病率的上升可能是生物因素和实践相关因素共同作用的结果(例如,更灵敏的诊断检测手段、人们认知度提高、纠正了既往漏诊情况,以及更新了疾病定义等),同时由于动脉粥样硬化事件后生存率的提高,患者在延长的生命中也可能继续患上其他心血管疾病。无论对观察到的这种转变作何解释,患病人数的不断增加都对医疗卫生服务和人群总体疾病负担有重要影响


现在能采取哪些行动呢?我们需要在心血管疾病构成发生变化的背景下重新审视当前的预防策略。对于许多心血管疾病,如非风湿性瓣膜病或心房颤动,当前的医疗实践仍主要集中于症状管理和疾病相关并发症的预防[19][20]。美国和欧洲临床学会最新发布的心血管疾病预防指南,以及临床实践中用于识别高危人群的风险评分,仍主要侧重于动脉粥样硬化性疾病[21][22]


要制定更全面的心血管疾病及其预后的一级预防战略,可能需要从加大研究力度入手,探究非动脉粥样硬化性心脏病的发病机制和潜在的可改变的危险因素,并确定有效的干预措施来改变这些因素。


对各种心血管疾病的有害暴露和潜在机制的研究,可能需要涵盖已经确定的心血管标志物和新的心血管标志物。动脉粥样硬化性心脏病的许多可改变的危险因素,包括血压、吸烟或身体活动不足,也与一系列其他心血管疾病有关,但其确切作用、影响程度及相互作用尚未完全明确[23-25]。也有研究报道了差异性影响,例如胆固醇与心房颤动、血压与静脉血栓栓塞,以及糖尿病与主动脉瘤风险之间呈负相关[25-27]。有待对这些负相关性进行更深入的研究,如果得到证实,会更充分地理解其意义。


除了公认的血管疾病危险因素外,近期发现的一些危险因素(如炎症、免疫介导性疾病、细胞衰老和癌症治疗)也已被证明会导致除动脉粥样硬化以外的一系列心血管疾病[28-30]。截至目前,针对这些新危险因素的有效干预措施的设计还落后于针对传统风险因素的干预措施,需要进行专门的研究和实施工作


近年来,多项药物干预措施在实现有效干预目标方面也取得了可喜的进展,现有和新型药物疗法均在预防非动脉粥样硬化性心脏病方面显示出潜力。例如,预防或延缓主动脉狭窄进展的方法正在研究中,脂蛋白(a)、维生素K或磷酸盐等新型生物标志物和治疗靶点已显示出潜力,相关试验正在进行中[31]。同样,心房颤动可能并不是衰老的必然结果,通过肾素-血管紧张素或醛固酮抑制等治疗方法,或可实现一级预防[32][33]。此外,降脂或降压等现有疗法在减少心力衰竭和主动脉瘤等疾病的发生方面也能够发挥作用[34][35]。SGLT2抑制剂和GLP-1受体激动剂等新型药物已显示出多效性,或可有助于预防心力衰竭、心律失常和瓣膜病,但其作用机制仍在研究中[36][37]


拓宽心血管疾病的预防方法可能还需要在许多其他方面转变视角,包括采用个性化和长期的风险预测模型,以更早地启动有针对性的预防措施,涵盖更广泛的事件谱。未来的风险评估模型可能会动态、精确地评估个人患心血管疾病的风险,并推荐最合适的预防治疗方案。欧洲和美国心脏学会的风险合作组织已经开始在不同人群中考虑更广泛的危险因素和疾病结局[38][39],未来可能会采取更多举措。


对不断变化的心血管疾病谱的认识,将有望推动加大预防非动脉粥样硬化性心脏病的研究力度,制定能够考虑多种心血管疾病结局风险的评分系统,开展临床试验以测试新型干预措施或探索现有干预措施的更广泛适应症,并最终制定循证的预防指南,覆盖日益增长的、对当前社会疾病负担有重要影响的各种心血管疾病。END


中文翻译仅供参考,所有内容以英文原文为准。

https://doi.org/10.1016/S0140-6736(25)00990-0


参考文献


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