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Introduction At present, the secondary prevention of ischemic stroke in China has limited benefits based on the current treatment plan.
Therefore, it is necessary to explore more other therapeutic targets to prevent ischemic stroke in clinical practice, so as to achieve the desired effect of secondary prevention
.
At the 7th Chinese Stroke Society Academic Annual Meeting and Tiantan International Cerebrovascular Disease Conference (CSA & TISC 2021) held on July 9-11, Professor Li Xiaogang from the Department of Neurology, Peking University Third Hospital gave a presentation on lipid-lowering treatment for stroke patients For the special report, Yimaitong was fortunate to have an exclusive interview with Professor Li after the meeting and gave a further explanation
.
Expert profile Professor Li Xiaogang • Doctor of Medicine (MD, PhD), postgraduate tutor • Associate Director and Chief Physician of Department of Neurology, Peking University Third Hospital • Associate Dean of Capital Airport District, Peking University Third Hospital • Associate of Rehabilitation Group, Neurology Branch of Chinese Medical Association Team Leader • Deputy Chairman of the Rehabilitation Group of the Neurology Branch of the Chinese Medical Doctor Association • Member of the Third Committee of the Stroke Prevention and Control Professional Committee of the Chinese Preventive Medicine Association • Member and Deputy Secretary-General of the Chinese Stroke Center Management Steering Committee • Deputy Secretary-General of the Beijing Association for Prevention and Treatment of Cerebrovascular Diseases President • Vice President of Beijing Society of Neurology • Deputy Chairman of the Acute Treatment Professional Committee of Beijing Association for Cerebrovascular Disease Prevention and Treatment Yi Maitong: What is the current status of stroke in China and what do you think is the effect of secondary prevention? According to Professor Li Xiaogang, the incidence of stroke in China has not yet reached an inflection point
.
China is a major stroke country.
The incidence, recurrence, disability, and mortality rates of stroke among 1.
4 billion people are very high.
This is a very heavy health burden for our country and needs to be taken seriously
.
Atherosclerosis is the main cause of ischemic stroke
.
At present, for the secondary prevention of ischemic stroke in China, the guidelines propose three cornerstones-ASA
.
They are: A-antiplatelet therapy, S-statin therapy, A-antihypertensive drug therapy
.
However, the effects of these three types of drugs are limited.
When the number of people in need of treatment (NNT) is used as an indicator of benefit, the NNT of antiplatelet drugs is 100, the NNT of statins is 230, and the NNT of antihypertensive drugs is 45.
The so-called NNT is the number of patients who need to be treated to achieve an absolute patient benefit
.
According to the standard secondary prevention effect, the benefits of ASA are indeed limited, and there are still many residual events.
Therefore, we need to explore other therapeutic targets to prevent ischemic stroke, so as to achieve better secondary prevention.
Effect
.
Yimaitong: At this Temple of Heaven meeting, you gave a special report on lipid-lowering treatment for stroke patients.
Could you please talk about the main lipid-lowering treatment plan for stroke patients in my country? Is it satisfactory? Professor Li Xiaogang Atherosclerosis is one of the most important causes of ischemic stroke.
At present, the most effective drugs in lipid-lowering treatment are still statins, but the application of statins in China is not ideal.
Use statin lipid-lowering therapy alone The risk of vascular events is reduced by 11% to 47%, and the risk of residual events in lipid-lowering treatment is still as high as 53% to 89%
.
According to the “Guidelines for the Clinical Management of Cerebrovascular Diseases in China” released in 2019, the target of low-density lipoprotein cholesterol regulation is lower than 1.
8mmol/L, but only about one-third of patients in China who can achieve this standard with statin therapy First, patients who do not meet the standard are very prone to recurrence of ischemic stroke.
The reasons are: Many patients or doctors are worried that the increased dose of statins will increase the side effects
.
➤Some patients stop taking the drug after reaching the LDL standard, and fail to use it for a long time
.
The above is not an ideal treatment method, but it is one of the main reasons for the high recurrence rate of ischemic stroke in China.
Therefore, the current rate of statin lipid-lowering standards in China is not high, which is a big worry
.
Yimaitong: At present, the effect of statins for lipid-lowering treatment is limited.
What targets do you think should be paid attention to to optimize the current lipid-lowering treatment plan? Professor Li Xiaogang’s dyslipidemia is the main risk factor for cardiovascular events in patients with atherosclerotic cardiovascular disease (ASCVD).
The 2016 Chinese Adult Dyslipidemia Prevention and Treatment Guidelines, 2018AHA/ACC Cholesterol Management Guidelines, and 2019ESC/EAS Dyslipidemia Management Guidelines are all Proposed: It is recommended that patients with ischemic stroke/TIA be managed according to the high-risk group of ASCVD
.
At present, it seems that the therapeutic effect of statins is indeed limited, and we need to pay attention to more targets
.
If you pay attention to the target of atherosclerosis, you must review its history
.
From the research mechanism of atherosclerosis, it is found that it is related to many mechanisms, such as abnormalities in platelets, endothelial function, and blood lipids
.
And there are two main targets that are easily overlooked, one is inflammation and the other is oxidative stress.
From these two aspects, we lack the corresponding drugs
.
The main mechanism of probucol that we usually use is anti-oxidative stress
.
Oxidative stress is the key to the formation of atherosclerotic plaques.
Oxidative stress induces an increase in the production of reactive oxygen species, damages the vascular endothelium, and triggers inflammation and immune responses.
At the same time, oxidative stress induces the oxidation of low-density lipoprotein (LDL), resulting in the formation of Oxidized low-density lipoprotein (ox-LDL) has a strong cytotoxic effect, and ultimately promotes the occurrence and development of atherosclerosis, causing plaque rupture, leading to cerebrovascular events
.
Therefore, in the future, statins combined with probucol will be needed to increase the antioxidant effect, which is also the best way to supplement the lipid-lowering effect of statins
.
Yimaitong: How effective is the lipid-lowering program combined with non-statins? Can it improve the status quo of low compliance rate? Professor Li Xiaogang’s statin treatment compliance rate is not particularly high, but some non-statin drugs can be combined to increase the blood lipid compliance rate
.
The 2016 Chinese Adult Dyslipidemia Prevention and Treatment Guidelines and the 2018 AHA/ACC Cholesterol Management Guidelines clearly pointed out that if the cholesterol level cannot reach the target, it is recommended that statins be used in combination with other lipid-lowering drugs
.
There are many new types of drugs, such as PCSK9 inhibitors, which are recently marketed and have a strong effect on lowering low-density lipoprotein cholesterol
.
There is also probucol, which has an antioxidant effect
.
In combination with statins, in addition to lowering the level of LDL-C, it strengthens the level of blood lipids, it can also improve the structure of the carotid artery and reduce the number of vulnerable plaques
.
In addition, other non-statin lipid-lowering drugs can also be used clinically, including cholesterol absorption inhibitor ezetimibe, and some niacin lipid-lowering drugs, etc.
, so that high-dose statin drugs can be avoided.
.
Combination medication will be a development direction in the future
.
Therefore, it is necessary to explore more other therapeutic targets to prevent ischemic stroke in clinical practice, so as to achieve the desired effect of secondary prevention
.
At the 7th Chinese Stroke Society Academic Annual Meeting and Tiantan International Cerebrovascular Disease Conference (CSA & TISC 2021) held on July 9-11, Professor Li Xiaogang from the Department of Neurology, Peking University Third Hospital gave a presentation on lipid-lowering treatment for stroke patients For the special report, Yimaitong was fortunate to have an exclusive interview with Professor Li after the meeting and gave a further explanation
.
Expert profile Professor Li Xiaogang • Doctor of Medicine (MD, PhD), postgraduate tutor • Associate Director and Chief Physician of Department of Neurology, Peking University Third Hospital • Associate Dean of Capital Airport District, Peking University Third Hospital • Associate of Rehabilitation Group, Neurology Branch of Chinese Medical Association Team Leader • Deputy Chairman of the Rehabilitation Group of the Neurology Branch of the Chinese Medical Doctor Association • Member of the Third Committee of the Stroke Prevention and Control Professional Committee of the Chinese Preventive Medicine Association • Member and Deputy Secretary-General of the Chinese Stroke Center Management Steering Committee • Deputy Secretary-General of the Beijing Association for Prevention and Treatment of Cerebrovascular Diseases President • Vice President of Beijing Society of Neurology • Deputy Chairman of the Acute Treatment Professional Committee of Beijing Association for Cerebrovascular Disease Prevention and Treatment Yi Maitong: What is the current status of stroke in China and what do you think is the effect of secondary prevention? According to Professor Li Xiaogang, the incidence of stroke in China has not yet reached an inflection point
.
China is a major stroke country.
The incidence, recurrence, disability, and mortality rates of stroke among 1.
4 billion people are very high.
This is a very heavy health burden for our country and needs to be taken seriously
.
Atherosclerosis is the main cause of ischemic stroke
.
At present, for the secondary prevention of ischemic stroke in China, the guidelines propose three cornerstones-ASA
.
They are: A-antiplatelet therapy, S-statin therapy, A-antihypertensive drug therapy
.
However, the effects of these three types of drugs are limited.
When the number of people in need of treatment (NNT) is used as an indicator of benefit, the NNT of antiplatelet drugs is 100, the NNT of statins is 230, and the NNT of antihypertensive drugs is 45.
The so-called NNT is the number of patients who need to be treated to achieve an absolute patient benefit
.
According to the standard secondary prevention effect, the benefits of ASA are indeed limited, and there are still many residual events.
Therefore, we need to explore other therapeutic targets to prevent ischemic stroke, so as to achieve better secondary prevention.
Effect
.
Yimaitong: At this Temple of Heaven meeting, you gave a special report on lipid-lowering treatment for stroke patients.
Could you please talk about the main lipid-lowering treatment plan for stroke patients in my country? Is it satisfactory? Professor Li Xiaogang Atherosclerosis is one of the most important causes of ischemic stroke.
At present, the most effective drugs in lipid-lowering treatment are still statins, but the application of statins in China is not ideal.
Use statin lipid-lowering therapy alone The risk of vascular events is reduced by 11% to 47%, and the risk of residual events in lipid-lowering treatment is still as high as 53% to 89%
.
According to the “Guidelines for the Clinical Management of Cerebrovascular Diseases in China” released in 2019, the target of low-density lipoprotein cholesterol regulation is lower than 1.
8mmol/L, but only about one-third of patients in China who can achieve this standard with statin therapy First, patients who do not meet the standard are very prone to recurrence of ischemic stroke.
The reasons are: Many patients or doctors are worried that the increased dose of statins will increase the side effects
.
➤Some patients stop taking the drug after reaching the LDL standard, and fail to use it for a long time
.
The above is not an ideal treatment method, but it is one of the main reasons for the high recurrence rate of ischemic stroke in China.
Therefore, the current rate of statin lipid-lowering standards in China is not high, which is a big worry
.
Yimaitong: At present, the effect of statins for lipid-lowering treatment is limited.
What targets do you think should be paid attention to to optimize the current lipid-lowering treatment plan? Professor Li Xiaogang’s dyslipidemia is the main risk factor for cardiovascular events in patients with atherosclerotic cardiovascular disease (ASCVD).
The 2016 Chinese Adult Dyslipidemia Prevention and Treatment Guidelines, 2018AHA/ACC Cholesterol Management Guidelines, and 2019ESC/EAS Dyslipidemia Management Guidelines are all Proposed: It is recommended that patients with ischemic stroke/TIA be managed according to the high-risk group of ASCVD
.
At present, it seems that the therapeutic effect of statins is indeed limited, and we need to pay attention to more targets
.
If you pay attention to the target of atherosclerosis, you must review its history
.
From the research mechanism of atherosclerosis, it is found that it is related to many mechanisms, such as abnormalities in platelets, endothelial function, and blood lipids
.
And there are two main targets that are easily overlooked, one is inflammation and the other is oxidative stress.
From these two aspects, we lack the corresponding drugs
.
The main mechanism of probucol that we usually use is anti-oxidative stress
.
Oxidative stress is the key to the formation of atherosclerotic plaques.
Oxidative stress induces an increase in the production of reactive oxygen species, damages the vascular endothelium, and triggers inflammation and immune responses.
At the same time, oxidative stress induces the oxidation of low-density lipoprotein (LDL), resulting in the formation of Oxidized low-density lipoprotein (ox-LDL) has a strong cytotoxic effect, and ultimately promotes the occurrence and development of atherosclerosis, causing plaque rupture, leading to cerebrovascular events
.
Therefore, in the future, statins combined with probucol will be needed to increase the antioxidant effect, which is also the best way to supplement the lipid-lowering effect of statins
.
Yimaitong: How effective is the lipid-lowering program combined with non-statins? Can it improve the status quo of low compliance rate? Professor Li Xiaogang’s statin treatment compliance rate is not particularly high, but some non-statin drugs can be combined to increase the blood lipid compliance rate
.
The 2016 Chinese Adult Dyslipidemia Prevention and Treatment Guidelines and the 2018 AHA/ACC Cholesterol Management Guidelines clearly pointed out that if the cholesterol level cannot reach the target, it is recommended that statins be used in combination with other lipid-lowering drugs
.
There are many new types of drugs, such as PCSK9 inhibitors, which are recently marketed and have a strong effect on lowering low-density lipoprotein cholesterol
.
There is also probucol, which has an antioxidant effect
.
In combination with statins, in addition to lowering the level of LDL-C, it strengthens the level of blood lipids, it can also improve the structure of the carotid artery and reduce the number of vulnerable plaques
.
In addition, other non-statin lipid-lowering drugs can also be used clinically, including cholesterol absorption inhibitor ezetimibe, and some niacin lipid-lowering drugs, etc.
, so that high-dose statin drugs can be avoided.
.
Combination medication will be a development direction in the future
.
