?????????? 2006 ????.
???????? ????????? ???????????? ?????????? ??????, ?????? ? ?????.
?????????? ?.?.??????
?? ??????? ?????????? ?????????? ??????????? ????????? ???????????? ???????? ??????????? (???) ? ???????????? ?????????? ?????? (???) ?? ????????? ???????????? ? 2001 ???? ???? ???????? ????? ?????? ?????????????? ????, ??? ????? ??????????? ??????? ? ????? ???????? ????? ??? ????? ???????? ?????????????? ?????? ? ????????? ? ??? ??? ?????? ???????????? ???????????????????? ????????. ?????????? ??????????? ????????????? ???? ????????? ?? ??????????? ???????? ??????????, ?????????? ????? ????????? ????????-?????????? ??????? ? ????? ???????, ???? ?????????? ?????????? ?????????????. ???????, ???????? ????????? ???????? ????? ? ????? ???????.
????????????? ?????? ???????? ??????????? ???????????? ? ?????????????? ??????????? ???????????? ???? ????????? ??? ????????? ?????????? ?????????? (????.1). ? ????????? ????????? ??????????? ????? ??????? ?????????????? ? ????????????, ???????????? ??? ? ??? (????. 2).
???????????? ???????????? ?? ????????????, ????????? ???????????? ?????????? ???????? ? ???/???. ????? ????, ?? ?????? ??????? ??? ????????? ????????? ??????? ????????????, ?????????????? ????? ?????? ?????????????? ??????????. ????? ???????, ??? ???????? ?????????? ????????? ???? ????????? ????????? ???????????? ?????????? ? ?????? ??????, ?????????? ? ???????????? ??????????. ?????????? ??????????? ????? ?? ???????? ???????? ???????? ???????, ?????????????? ? ????????? ????? ? ?????????? ? ????? ????????? ????? 50 000 ??????? [33-37], ??????? ? ????????????? ???????? ????? ??????? ??????? ??????????? ? ????? ???????? ??????????? ????????? ??????, ?????? ? ????? 2004 ???? (ATP III) [6]. ? ???? ????????? ???????????? ?? ??? ?????? ??????? ?????? ????? ???? ??????? ??? ????????? ? ??? ? ?????????? ??????? ?????, ??????? ??????? ? ???. ??????????????, ???? ????????? ????????? ??? ?????????? ?????????????????? ??????????. ??? ????? ?????? ????? ???????? ATP III 2004 ????, ???? ???????????? ?????????? ???? ?????????????? ???????????? [8,9]. ?? ????????? ????????? ????? ? ????????????? ??????? ? ??????? ?????? ?? ??? ???? 100 ??/?? (2.6 ?????/?) ? ???? ??????? ? ??? ? ? ????? ?????? ??????????? ?????????????, ????????? ???????? ?? ?????????????? ???????? ????? ?????????? ? ??????? ???? 1.8 ?????/?. ? ??????, ???? ? ???????? ??????????????? ???? ?????? ??????? ????? ????? 1.8 ?????/?, ????????? ?????????????? ??????????? ?????????? ???? ??????? ??? ?????? ?? ??????????????????? ???????? ? ?????????????. ? ??????, ???? ?? ???? ???????????? ?????????????????? ??????? ?? ??????? ??????? ???????? ?????? (??-?? ????? ???????? ????????? ?????? ?? ???), ? ????? ????????? ??????????? ???????? ?????? ?? ??? ????? ??? ?? 50% ?? ??????????. ???????????? ???????? ????????? ?? ????????? ???????????? ? ?? ??????????? ????????? ???????????? ??????????? ???? 2004 ???? ??? ????????? ??? ??????????????????? ?????????, ?? ? ??????? ?????? ?????????? ??? (>20% ?? 10 ???), ??????? ???????? ?????? ? ????????? ?????????? ???????? ?????. ??? ???? ????????? ??????????? ??????? ??????? ?? ??? < 2.6 ?????/?. ??? ????? ????? ??????? ??????? ?? ????????? ? ????????? ??? ??? ? ? ????????? ??????? ?????.
?????? ????????? ? ??????? ? ?????????????????? ???????, ? ????????? ?????????? ???????? ?????????? ???????????? ?? ????????? ???????????? ? ??????????? ?????? ???????. ? ?????????, ????????? ???????????? ?? ?????????? ???????????? ????? ??????? ??????????? ???????? ? ????? ????????????? ?????????? ???????. ???????? ?????????? ?????????? ????? ?????? ??? ????????. ?????????? ????????? ??????????? ????????? ??? ??? ??????????? ?????? ???????????? ???????????? ? ??????? ? ?????????? ???????? ?????? ?????????. ???????, ? ?????? ??????????? ???????????? ????? ????????? ?????????? ??????? ?????????????? ???????????? ?? ???????????? ?????????? ?????????? ??? ? ????????? ???????????? ??????? ????? <? ?????? ????????? ????????????> ? ?????????? ???????? ?????? ?????????. [26]
? ?????? ???????????? ??????? ????????? ???????????? ? ????????????????? ??????????. ???????? ?????? ??????? ?? ???????? ?? ????????????? ? ???????????? ???, ?????????? ?????? ?????? ?????? ????????????? ???? ????????? ? ??????????? ??? ????????????? ????????-?????????? ???????, ????????? ??? ????????? ??? ????????? ? ?????? ????? ?????????? ?????? [38].
?????? ??????? ???????????? ????????????, ??? ??????? ??? ?? ???????? ???? ??????????????, ?????????? ? ???? ??????????? ?????????, ??? ?????? ???????? ?? ???????????? ??????????. ?????? ? ???, ?????? ????????, ??? ???????????? ???????????, ??????? ? ??????? ???? ? ??????? ??????? ???? ???????????? ? ??????????? ?????????????. ? ????? ? ??? ?????? ????????? ?????? ???????? ???????? ? ??????? ??????????? ????????? ????????? ????????? ?????.
??????? 1. ???????????? ??? ? ??? ?? ????????? ???????????? ? ????????? ? ?????????? ???????? ? ??????? ????????????? ???????1. ?????????? 2006 ????.
???? ?????????????
????????????? ????????????? ? ????????? ?????? ????????????? ? ????????????
???????
????:
?????? ???????????. ???????? «??????????» ???????.
· ????? ? ??????? ?? ?????? ?????? ? ?????. I (B)
· ????????????? ?????????? ?? ??????? ???? ???????. I (B)
· ??????? ????????? ???????? ??????? ??????. I (B)
· ?????? ???????? ? ?????????? ????? ?? ?????? ?? ???????. I (B)
· ???????????? ?????????? ??????????, ????????? ??? ??????? ? ??????????????? ?????????? ??? ????????? ?????????????? (??????? ?????????????? ??????? ? ????????? <bupropion>). I (B)
· ????????????? ?????????????? ?? «?????????? ???????» ?? ?????? ? ????. I (B)
???????????? ????????
????:
<140/90 ?? ??.??. ???
<130/80 ?? ?? ?? ??? ???????? ??????? ? ??????????? ??????????? ?????
??? ???? ?????????:
· ?????? /?????????? ???? ?? ????????? ?????? ?????: ???????? ?? ?????? ????, ?????????? ?????????? ??????????, ???????? ?? ????????????? ????????, ??????????? ??????????? ??????. ????????? ???????????? ?????? ???????, ??????, ???????? ????????? ? ?????? ??????????? ????. I (B)
??? ????????? ? ???????????? ????????? ???? ????????:
· ???????? ?? ????????????? ????????????? ????????, ??????? ? ????-?????????? ?/??? ??????????? ???, ???????? ??? ????????????? ?????? ?????????, ???????? ????????? ????????? ??? ?????????? ??????? ??????? ??. I (A)
??????? ???????
????:
?? ??? < 2.6 ?????/?
???? ???????????? > 2.26 ?????/? – ??-???2 ?????????? ?????? ???? < 3. ?????/?
??? ???? ?????????:
· ????????? ????????????. ??????? ??????????? ?????????? ????? (<7% ?? ????? ???????????? ????), ?????-?????? ?????? ? ??????????? (< 200 ??/?). I (B)
· ?????????? ???????????? ????????/???????? (2? ? ????), ????????? (>10 ?/????) ????????????? ??????? ??????? ?? ???.
· ?????????? ?????????? ?????????? ?????????? ? ???????? ?? ?????? ????. I (B)
· ?????????? ???????? ????????? ??????????? ?????-3 ?????? ?????? ? ???? ???? ?? ????3 ??? ?????? (1 ?/????) ? ????? ???????? ?????. ??? ??????? ???????????????????? ????????? ????? ??????? ????. IIa (B)
?????????????????? ???????:
?????????? ???????? ??????? ??????? ? ???? ?????????. ??? ?????? ?????????? ??? ?????? ?????????? ??????? ?????? ???? ?????????? ? ?????? 24 ???? ??????????????. ??? ??????????????????? ????????? ?????????????????? ??????? ??????????? ?? ??????? ?? ??????????. ???? ???????????? ???????? ?????????:
· ?? ??? ?????? ???? ???? 2.6 ?????/?, ????? ????
· ???? ????????? ??? ???????? ???????? ?????? ????? ???? 1.8 ?????/? IIa (A)
· ???? ???????? ??????? ?? ??? >2.6 ?????/? – ????? ?? ??????????? ?????????????????? ???????.4 I (A)
· ???? ?? ???? ?????????????????? ??????? ????? > 2.6 ?????/? – ?????????? ????????????????? ??????? (???????? ?????????? ??????? ????????? 5). I (A)
· ???? ???????? ??????? ?? ??? >2.6 ?????/? ? > 1.8 ?????/?, ???????? ?????????? ??????? ??? ???????? ????? ?????????? ???? 1.8 ?????/?. Iia (B)
· ???? ??????? ????????????? ? ???????? ?? 2.26 ?? 5.6 ?????/?, ??????? ??-??? ??????????? ?????? ???? ???? 3.4 ?????/? I (B) ? ?????:
· ?????????? ???????? ??-??? ??????????? ???? 2,6 ?????/? IIa (B) ? ??????? ????????? ??????????????? ????????????:
Ø ?????????????? ???-????????? ??????? I (B) ???
Ø ?????????? ??????????? ???????6 (????? ???-????????? ???????) IIa (B) ???
Ø ??????? ?????????7 (????? ???-????????? ???????) IIa (B)
· ???? ??????? ????????????? > 5.65 ?????/?7, ???????? ??????? ?????? ??? ?????????????? ??????? ??????????? – ?????? ??? ??????????? ??????? ?? ?????????? ???-?????????? ?????????; ????????? ??????????? ?????? ????? ???????? ?????????????. ?? ??????????? ????????????? ??????? ???????? ?????? ??-??? ??????????? ???? 3.4 ?????/?. I (C)
?????????? ??????????
????:
30 ??? ? ????, 7 ???? ? ?????? (??????? 5 ???? ? ??????)
· ??? ???? ????????? – ??????? ????????????? ?????????? ???????? ?? ???????? ?/??? ?? ??????????? ????? ? ?????????? ????????? ??? ????????? ?????????? ????????????. I (B)
· ???? ????????? ????????????? ????????? ???????? ?????????? ????????, ???????? ??????? ?????? ?? 30-60 ??? ? ????, ?????????? ?????????. ?????????? ????????? ?????????? ?????????? ? ???????????? ????? (???????? – ?????? ?? ????? ???????? ?? ??????, ?????? ? ????, ???????? ????). I (B)
· ????????????? ?????????? ?????????? ? ??????????? 2 ???? ? ??????. IIb (C)
· ??? ????????? ? ??????? ??????? ????? – ????? ???, ????????????????, ??? ????????? ??????????????? – ?????????? ?????????? ?????????? ?? ????????? ??? ????????? ????. I (B)
????? ????
????:
?????? ????? ???? ? ???????? 18.5 – 2.9 ??/?2
?????????? ?????:
??? ?????? - < 89 ?? (35 ??????)
??? ?????? -102?? (40 ??????)
· ??????? ?????? ????? ???? ?/??? ?????????? ????? ?? ?????? ?????? ? ?????. ????????? ?????????? ???????? ? ????????????? ??????????? ????? ???? ?? ??????? ?????? ????? ????????? ??? - ?????????? ??????????, ??????????? ???????????? ????. ??? ????????????? - ??????? ? ?????????????????? ??????????. I (B)
· ???? ?????????? ?????, ?????????? ?? ?????? ??????? ??????????? ?????? > 89 ?? ? ?????? ? 102?? ? ??????, ?????????? ???????????? ??????????????? ????????? ?????? ????? ?? ?????? ??????????????? ????????. ??? ??????? ????????? – ?????? ??????????????? ?????????????. I (B)
· ????????? ???? ???????, ???????????? ?? ???????? ???? – ?????????? ????? ?? 10% ?? ????????? ??????. ????? ????? ????? ?????????? ???????? ???????? ???????? ?????, ???? ?? ????????? ??????? ??????? ??? ????????? ????????. I (B)
???????? ??????
????:
??????? HbA1C< 7%
· ?????? ????????? ?????? ????? ? ?????????????? ??? ?????????? ???????? ? ???????? ?????? HbA1C. I (B)
· ?????? ???????? ??????????? ?? ?????? ??????? ????? (?????????? ??????????, ????????? ????, ???????? ?? ? ?????? ???????????, ??? ???? ??????? ????). I (B)
· ?????????????? ??????? ??????? ? ?????? ????? ???????? ??? ? ??????????????, ??????? ????????? ?? ?????? ???????. I (C)
?????????????????? ???????? ? ??????????????
· ????????? ??????? ? ???? 75-162 ??/???? ?? ????????????? ?????? ????? ???? ?????????, ???? ??? ????????????????. I (A)
Ø ??????? ????? ???????? ??????????? ???????????? ??????? ?????? ???? ???????? ? ???????? 48 ????? ??? ?????????????? ???????? ??????. ? ???? ?????? ???????? ?????????? ???? ?? 100 ?? 300 ??/????. ?????????? ???? ???? 162 ??/???? ? ???? ?????? ????????? ?? ?????????? ?? 1 ????. I (B)
· ?????????/?????????? ????? 75 ??/???? ???????????? ? ?????????? ? ????????? ?? 12 ??????? ????? ??????? ??????????? ???????? ??? ????? ??????????? ????????????? ?? ?????????????? (>1 ??? ??? ??????????? ??????, >3 ??? ??? ??????? ? ??????????? ? > 6??? ??? ??????? ? ?????????????). I (B)
Ø ????????? ????? ????????????? ?????????? ??????? ????????????? ??????? ????????? ????? ??????? ???? ???????? - 325 ??/???? (?? >1 ???. ??? ???????? ??????, ?? >3 ???. ??? ??????? ? ??????????? ? ?? >6??? ??? ??????? ? ?????????????). I (B)
· ? ????????? ? ??????????? ? ????????? – ??????????????? ??? ?????????? ???????????? ????????, ??????????? ??????????, ??? ?????????????? ?????? ? ????????? ?????? – ?????????? ???????????? ??? ?? ?????? ?? 2.0 ?? 3.0. I (A)
· ????????????? ????????? ???????????? ? ????????? ? ????????????? ??????? ? ?????? ???????????? ? ??????? ??????? ????????. I (B)
????????? ?????-??????????? ??????????????? ???????
?????????? ???:
· ????????? ?? ????????????? ?????? ???? ???? ????????? ? ???????? ??????? ?? <40%, ??? ???????????? ???????????, ???????? ??????? ??? ??????????? ??????????? ?????, ???? ??? ????????????????. I (A)
· ??????????? ??????????? ??????????? ??????? ? ???? ??????? I (B)
· ? ???????? ?????????? ??????????????? ????????????? ???? ????? ???? ??????????? ? ????????? ?????? ??????: ? ?????????? ???????? ??, ? ?????? ??????????????? ????????? ????? ? ????? ????????? ????????????????. Iia (B)
??????????? ?????????? ????????????:
· ????????? ? ?????????? ????????? ??????????????? ??? ????? ???????? ???????? ?? ????????? ???????? ??????? ?? <40%, ??????? ?? ????????? ?????????? ???. I (A)
· ??????????? ??????????? ?????????? ? ?????? ????? ??????? ? ???????????????? ??????????? ???. I (B)
· ??????????? ??????????? ?????????? ? ?????????? ? ???????????? ??? ? ????????? ? ????????????? ????????? ????????????????. IIb (B)
??????????? ????????????:
· ? ????????? ????? ???????? ???????? ?? ????????? ???????? ??????? ?? <40%, ??? ????????? ????????? ???????? ???????8 ?/??? ?????????????9, ??????? ??? ???????? ??????????????? ???? ??????????? ??? ? ????-?????????, ? ????? ???? ???????? ??????, ???? ??????? ????????? ???????????????. I (A)
????-???????????????
· ????????? ?? ????????????? ?????? ???? ???? ????????? ?????????? ??????? ????????, ?????? ?????????? ??????? ??? ??? ?????????? ??????? ?????? ????????? ?????????? ?? ??????? ??????? ????????? ???????????????, ???? ??? ????????????????. I (A)
??????????? ??????????? ??????????? ??????? ? ???? ??????? ? ???????????? ???????????????????? ????????? ??????? ??? ? ???????? ????????, ???? ??? ????????????????. IIa (C)
?????????? ?????? ?????? ??????
· ???????? ? ????????-??????????? ????????????? ?????? ???? ????????????? ?????? ??????. I (B)
??????????:
1. ?????????????? ???????????? ????????? ? ??????? ? ????????????? ??? ? ?????? ??????????????????? ???????????, ??????? ???????????? ?????????????? ???????, ?????, ?????? ???????. ??????? ????????? ????????????? ? ???????? ???????? ????? ??????????? ? ????????? ????????? ??? ? ???.
2. ??-??? ?????????? = ????? ?????????? – ?????????? ???
3. ?????????? ? ???????? ??????? ?????? ???????????? ???????????? ????, ????? ???????? ?????????? ??????????? ?????-?????.
4. ??? ????????????? ???-????????? ??????????, ?????????? ?? ??????? ???? ?????????? 30-40% ???????? ?? ???. ???? ?? ??????? ??????? ??????? ???????? <1.8 ?????/?, ????????????? ??????????? ????????? ???? ??????? ??? ??????????? ???????? ???????? ? ????????? ???????. ???? ??????? ??????? < 1.8 ?????/? ?? ??????? ??????? ?????????? ???????? ??-?? ????? ???????? ????????? ???????? ???????, ????????? ?????????? ???????? ?? ??? ?? 50% ? ??????? ??????????? ????????? ??? ? ?????????? ? ?????? ?????????????????? ???????.
5. ??????????? ???? ??????? ? ??????????, ????????????? ??????? ??????, ??????????? ????????.
6. ?????????????? ??????? ???? ??????? ? ???????? ????? ????????? ???? ??????? ????????, ? ????? ? ??? ? ????? ?????????? ?????? ??????????? ? ???????????? ????????? ?????????. ?????????? ??????????? ??????? ? ??????? ?????????? ??????? ? ???????? ??????????????????? ???????? ?? ?????????.
7. ??????? ? ????? ??????? ??????? ????????????? ??????? ?????????????? ?? ???????????? ????????. ????????????? ????????????? ?????? ?????? ???????????? ??????????????? ??? ???????????? ????????????? > 2.26 ?????/?.
8. ????????? ?????? ???? ???? 2.5 ??/?? ??? ?????? ? ???? 2.0 ?????/? ??? ??????
9. ?????????? ????? ? ????? ???? 5 ?????/?.
??????? 2. ????????????? ????????? ???????????? ? ?????? ????????? ? ????????????.
??????? ?????????????? ?????????? ?????????????:
????? I. ?????????? ?????????????? ?/??? ????? ??????????, ??? ????????? ??? ????? ??????? ??????? ? ??????????.
????? II. ??????? ?????????????? ?????? ?/??? ?????? ????????? ? ??????????/ ????????????? ?????????????
????? II?. ?????? ????????????? ??? ?????? ? ?????? ?????????????.
????? IIb. ???????????????? ????????????? ????? ????????.
????? III. ?????????? ?????????????? ?/??? ????? ??????????, ??? ????????? ??? ????? ??????? ?? ???????, ?? ?????????? ? ? ????????? ??????? ????? ???? ????????.
??????? ?????????? ?????????????, ??????? ? ?????? ????????????:
??????? ???????????? ? (?????????) – ?????? ???????? ?? ?????? ????????????????? ??????????? ?????????????.
??????? ???????????? ? (?????????????) – ?????? ???????? ? ???????????? ?????????? ????????????????? ????????????, ??????????????????? ????????????? ??? ?????????, ??????????????? ??? ??????????.
??????? ???????????? ? (??????) – ???????????? ???????????? ? ??????????????? ?? ?????????? ?????????.
?????? ??????????
1. Smith SC Jr, Blair SN, Bonow RO, Brass LM, Cerqueira MD, Dracup K,Fuster V, Gotto A, Grundy SM, Miller NH, Jacobs A, Jones D, Krauss RM, Mosca L, Ockene I, Pasternak RC, Pearson T, Pfeffer MA, Starke RD, Taubert KA. AHA/ACC Scientific Statement: AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation. 2001;104:1577–1579.
2. Mosca L, Appel LJ, Benjamin EJ, Berra K, Chandra-Strobos N, Fabunmi RP, Grady D, Haan CK, Hayes SN, Judelson DR, Keenan NL, McBride P, Oparil S, Ouyang P, Oz MC, Mendelsohn ME, Pasternak RC, Pinn VW, Robertson RM, Schenck-Gustafsson K, Sila CA, Smith SC Jr, Sopko G, Taylor AL, Walsh BW, Wenger NK, Williams CL; American Heart Association. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation. 2004;109:672– 693.
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5. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001;285:2486 –2497.
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8. LaRosa JC, Grundy SM, Waters DD, Shear C, Barter P, Fruchart JC, Gotto AM, Greten H, Kastelein JJ, Shepherd J, Wenger NK; Treating to New Targets (TNT) Investigators. Intensive lipid lowering with atorvastatin in patients with stable coronary disease. N Engl J Med. 2005;352: 1425–1435. 9. Pedersen TR, Faergeman O, Kastelein JJ, Olsson AG, Tikkanen MJ, Holme I, Larsen ML, Bendiksen FS, Lindahl C, Szarek M, Tsai J; Incremental Decrease in End Points Through Aggressive Lipid Lowering (IDEAL) Study Group. High-dose atorvastatin vs usual-dose simvastatin for secondary prevention after myocardial infarction: the IDEAL study: a randomized controlled trial. JAMA. 2005;294:2437–2445. Erratum in: JAMA. 2005;294:3092.
10. Baigent C, Keech A, Kearney PM, Blackwell L, Buck G, Pollicino C, Kirby A, Sourjina T, Peto R, Collins R, Simes R; Cholesterol Treatment Trialists’ (CTT) Collaborators. Efficacy and safety of cholesterollowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Lancet. 2005;366:1267–1278. Erratum in: Lancet. 2005;366:1358.
11. Ballantyne CM, Abate N, Yuan Z, King TR, Palmisano J. Dosecomparison study of the combination of ezetimibe and simvastatin (Vytorin) versus atorvastatin in patients with hypercholesterolemia: the Vytorin Versus Atorvastatin (VYVA) study. Am Heart J. 2005;149: 464–473. Erratum in: Am Heart J. 2005;149:882. 12. de Lemos JA, Blazing MA, Wiviott SD, Lewis EF, Fox KA, White HD, Rouleau JL, Pedersen TR, Gardner LH, Mukherjee R, Ramsey KE, Palmisano J, Bilheimer DW, Pfeffer MA, Califf RM, Braunwald E; A to Z Investigators. Early intensive vs a delayed conservative simvastatin strategy in patients with acute coronary syndromes: phase Z of the A to Z trial. JAMA. 2004;292:1307–1316.
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