Treating plaque, not data!!作者認為治療LDL不如量測carotid plaque

Treating Disease, Not Risk Factors

Observational data suggest that using total carotid arterial plaque burden to guide therapy can improve markers of atherosclerotic disease.

Quantitative measures of atherosclerosis, such as carotid intima–media thickness, are considered to be strong surrogate markers of disease progression. However, patients with hyperlipidemia are typically treated to target LDL and HDL levels, without regard to quantitative measures of plaque. In 2001, investigators at a vascular prevention clinic in western Ontario, Canada, began using the results of ultrasound measurement of total carotid plaque area, rather than lipid levels, to guide treatment in adults with known atherosclerotic disease. They compared their plaque-progression results through 2007 with those of the 5-year period before 2001, during which target lipid levels were used to guide treatment.

The investigators included serial plaque measurements from 4378 patients (47% women). Mean age at referral was 60 overall; during 1997–2001, mean age increased from 50 to 61 as the proportion of patients referred after a stroke grew. In 2001–2002, plaque was progressing in 55% of patients and regressing in 26%. By 2006, these proportions had essentially reversed: Plaque was regressing in 50% and progressing in 27%. In earlier years, patients with plaque progression had higher levels of LDL than those with regression. However, by 2007, LDL levels in patients with progression were approximately half as high as in earlier years and were actually lower than LDL levels in patients with regression.

Comment: The rationale for this treatment paradigm is that, as the authors put it, "treating arteries without measuring plaque would be like treating hypertension without measuring blood pressure." In this single-center study, treatment based on carotid total plaque area led to a substantial increase in plaque regression as compared with treatment based on lipid levels. However, these results must be tested in a large randomized trial with hard clinical outcomes before a major shift in clinical practice can be recommended.