Lipidsenker und arterielle Gefäßwand

Zusammenfassung

Die Behandlung mit Lipidsenkern, in erster Linie mit CSE-Hemmern, stellt heute aufgrund des umfassenden Nachweises ihrer Wirksamkeit in Regressions- und Survival-Studien eine evidenzbasierte Therapie der koronaren Herzkrankheit (KHK) dar. Obwohl in den Regressionsstudien vom angiographischen Diameterzugewinn her eine nur leichtgradige, wenn auch signifikante Verbesserung beobachtet wurde, war damit eine überraschend deutliche Senkung klinischer Ereignisse verbunden, die sich in großen, von sequentiellen angiographischen Beobachtungskonzepten unabhängigen Survival-Studien bis hin zur Mortalitätssenkung eindrucksvoll bestätigen ließ. Dieses »Paradoxon der Regressionsstudien« wird heute neben der LDL-Senkung den »Non-lipid-Effekten« der Cholesterinsenker zugeschrieben. Darunter versteht man die Plaquestabilisation, die Reduktion der Thrombusbildung, antiinflammatorische Effekte und die Verbesserung der endothelialen Dysfunktion. Obwohl zu anderen Arteriosklerosemanifestationen als der KHK weitaus weniger gesicherte Erkenntnisse vorliegen, ist anzunehmen, daß auch bei diesen eine LDL-Senkung auf <100 mg/dl mit CSE-Hemmern zur effektiven Sekundärprävention beitragen kann. Eine generelle Gabe unabhängig vom nachweisbaren LDL-Spiegel ist heute ebenso in Diskussion wie der frühe Einsatz beim akuten Koronarsyndrom. Aufgrund neuer Erkenntnisse ist zu erwarten, daß in naher Zukunft bei bestimmten Konstellationen wie Diabetes mellitus oder niedrigem HDL auch über den Einsatz von Fibraten in der Sekundärprävention diskutiert werden muß.

Summary

Due to the comprehensive evidence of their efficacy in regression and survival studies, treatment with hypolipidaemic agents, primarily CSE inhibitors, is regarded as evidence-based therapy of coronary heart disease (CHD). Although the increase in vessel diameter observed at angiography in regression studies marked only a slight, but significant, improvement, it was associated with a surprisingly pronounced reduction in clinical results. These have been impressively confirmed in major survival studies, independently of sequential angiographic observation concepts, where they even led to a decrease in mortality. This “paradox of the regression studies” these days is attributed to the “non-lipid” effects of cholesterol-lowering agents. These are defined as plaque stabilisation, reduced thrombus formation, antiinflammatory effects, and improvements in endothelial dysfunction. Although considerably fewer firm data are available for other arteriosclerosis manifestations apart from CHD, it must be assumed in these cases too that reducing LDL (100 mg/dL with CSE inhibitors can contribute toward effective secondary prevention. General administration, immaterial of the demonstrable LDL level, is under discussion, as is early use for acute coronary symptoms. More recent findings lead us to expect discussions in the near future on the use of fibrates in secondary prevention of such conditions as diabetes mellitus or low LDL levels.

Schlüsselwörter

CSE-Hemmer - Fibrate - Plaquestabilisation - kardiovaskuläre Sekundärprävention

Keywords

CSE inhibitors - fibrates - plaque stabilisation - secondary prevention of cardiovascular disease

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