2025年欧洲最新血脂异常管理指南要点解读

查道刚; 吴平生

doi:10.16766/j.cnki.issn.1674-4152.004236

2025年欧洲最新血脂异常管理指南要点解读

doi: 10.16766/j.cnki.issn.1674-4152.004236

查道刚^,,
吴平生

南方医科大学南方医院全科医学科，广东广州 510515

详细信息

通讯作者:
查道刚, E-mail: zha@smu.edu.cn

中图分类号: R589.2
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出版历程
- 收稿日期: 2025-09-18
- 网络出版日期: 2026-01-07

Key points interpretation of the latest European guidelines for dyslipidemia management in 2025

ZHA Daogang^,,
WU Pingsheng

Department of General Practice, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China

摘要

摘要: 动脉粥样硬化性心血管疾病是我国城乡居民死亡的首要原因，而高脂血症是动脉粥样硬化性心血管疾病的关键危险因素之一，掌握最新血脂异常管理指南具有重要意义。2025年，欧洲心脏病学会及欧洲动脉粥样硬化学会发布了《2019 ESC/EAS血脂异常管理指南：2025重点更新》。主要内容包括：推荐采用SCORE2及SCORE2-OP替代传统SCORE模型，用于心血管风险评估，强调对风险增强因素进行个体化考量的意义；推荐新型降脂药物用于他汀不耐受或疗效欠佳者；倡导急性冠脉综合征患者在住院期间早期实施强化联合降脂治疗；建议成人至少进行一次Lp(a)检测，尤其是高风险人群；高甘油三酯血症患者可考虑使用高纯度二十碳五烯酸乙酯；推荐年龄≥40岁的HIV感染者使用他汀进行一级预防；具有高心血管毒性风险的化疗患者应考虑使用他汀；不推荐无明确获益证据的膳食补充剂用于降脂。本文拟对上述要点进行解读，旨在助力全科医生深入理解更新内容，在临床实践中更好地优化血脂管理策略。
- 血脂异常 /
- 心血管风险 /
- 降脂药物 /
- 脂蛋白(a) /
- 高甘油三酯血症
Abstract: Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death among urban and rural residents in China, and hyperlipidemia is one of the key risk factors for ASCVD. It is therefore of great significance to master the latest guidelines for the management of dyslipidemia. In 2025, the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS) released "2025 Focused update of the 2019 ESC/EAS Guidelines for the Management of Dyslipidaemias". The main contents include: recommending the use of SCORE2 and SCORE2-OP to replace the traditional SCORE model for cardiovascular risk assessment, emphasizing the importance of individualized consideration of risk-enhancing factors; recommending novel lipid-lowering drugs for patients with statin intolerance or suboptimal efficacy; advocating early intensive combined lipid-lowering therapy in hospitalized patients with acute coronary syndrome; suggesting that adults should undergo at least one Lp(a) measurement, especially high-risk individuals; considering high-purity icosapent ethyl for patients with hypertriglyceridemia; recommending the use of statins for primary prevention in HIV-infected individuals aged ≥40 years; considering statin use in cancer patients at high risk of chemotherapy-related cardiovascular toxicity; and not recommending dietary supplements without proven benefit for lipid lowering. This article aims to interpret the key updates, with the goal of assisting general practitioners in better understanding the new recommendations and optimizing lipid management strategies in clinical practice.
- Dyslipidaemia /
- Cardiovascular risk /
- Lipid-lowering drugs /
- Lipoprotein(a) /
- Hypertriglyceridaemia

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表 1 心血管危险分层类别

Table 1. Cardiovascular risk categories

危险分层	具体内容
极高危	具有以下任一情况的人：
	●临床确诊或影像学检查明确存在的ASCVD。临床诊断ASCVD包括：既往急性冠脉综合征(心肌梗死或不稳定型心绞痛)、慢性冠脉综合征、冠状动脉血运重建手术(经皮冠状动脉介入治疗、冠状动脉搭桥术或其他血管重建术)、脑卒中和短暂性脑缺血发作，以及外周动脉疾病。影像学明确证实的ASCVD特指可明确预测临床事件的特征表现，例如冠状动脉造影、CT扫描、颈动脉超声或股动脉超声检测到明显异常的斑块(狭窄程度通常大于50%)，或CT检查显示冠状动脉钙化积分显著升高(>300)
	●糖尿病伴有靶器官损害(微量蛋白尿、视网膜病变或神经病变)，或至少合并3种主要危险因素，或病程超过20年的早发1型糖尿病
	●重度慢性肾脏疾病[eGFR < 30 mL/(min·1.73 m²)]
	●采用SCORE2或SCORE2-OP模型评估10年致命性或非致命性CVD风险≥20%
	●患有ASCVD或存在其他主要危险因素的家族性高胆固醇患者
高危	具有以下任一情况的人：
	●单个风险因素显著升高，特别是TC>8 mmol/L、LDL-C>4.9 mmol/L或血压≥180/110 mmHg
	●不伴有其他主要风险因素的家族性高胆固醇患者
	●无靶器官损害、病程≥10年或存在其他风险因素的DM患者
	●中度慢性肾脏疾病[eGFR 30~59 mL/(min·1.73 m²)]
	●采用SCORE2或SCORE2-OP模型评估10年致命性或非致命性CVD风险≥10%，但 < 20%
中危	具有以下任一情况的人：
	●糖尿病病程 < 10年且无其他危险因素的年轻患者(1型糖尿病＜35岁；2型糖尿病 < 50岁)
	●采用SCORE2或SCORE2-OP模型评估10年致命性或非致命性CVD风险≥2%，但 < 10%
低危	●采用SCORE2或SCORE2-OP模型评估10年致命性或非致命性CVD风险 < 2%
注：ASCVD为动脉粥样硬化性心血管疾病(atherosclerotic cardiovascular disease)，eGFR为估算肾小球滤过率(estimated glomerular filtration rate)，CVD为心血管疾病(cardiovascular disease)。1 mmHg=0.133 kPa。

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表 2 基于SCORE2和SCORE2-OP算法的风险估计之外需要考虑的风险增强因素

Table 2. Risk modifiers for consideration beyond the cardiovascular risk estimates generated by the SCORE2 and SCORE2-OP algorithms

类别	因素
人口统计学/临床状况	早发性心血管疾病家族史(男性＜55岁；女性＜60岁)
	高风险种族(如南亚人等)
	应激症状和心理社会压力源
	社会剥夺
	肥胖
	缺乏体力活动
	慢性免疫介导/炎症性疾病
	主要精神疾病
	过早绝经史
	子痫前期或其他妊娠期高血压疾病
	人类免疫缺陷病毒感染
	阻塞性睡眠呼吸暂停综合征
生物标记物	持续性升高的hs-CRP(>2 mg/L)
	Lp(a)升高[>50 mg/dL(105 nmol/L)]
注：hs-CRP为超敏C反应蛋白(hypersensitive C-reactive protein)。

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表 3 推荐意见一：关于无已知心血管疾病患者的心血管危险评估建议

Table 3. Recommendation 1 - Cardiovascular risk estimation in individuals without established cardiovascular disease

推荐内容	证据等级	证据水平
SCORE2推荐用于无明确ASCVD、DM、CKD、遗传性/罕见脂代谢或血压异常的表面健康受试者中，以评估10年致死性和非致死性CVD风险	Ⅰ	B
SCORE2-OP适用于无明确ASCVD、DM、CKD、遗传性/罕见脂质或血压异常的≥70岁表面健康人群，用于估计10年致死性和非致命性CVD风险	Ⅰ	B
通过影像学检查发现亚临床冠状动脉粥样硬化或CT检查发现冠状动脉钙化积分升高，应视为中危人群或危险分层临近治疗决策阈值患者的风险增强因素	Ⅱa	B
风险增强因素应当纳入对中度风险个体或临近治疗决策阈值的个体的风险调整	Ⅱa	B
推荐启动降低LDL-C的药物治疗用于以下人群的一级预防：	Ⅰ	A
●极高风险和LDL-C≥1.8 mmol/L(70 mg/dL)，或
●高风险和LDL-C≥2.6 mmol/L(100 mg/dL)
同时采取最优化的非药物治疗措施，以降低CVD风险
建议启动降低LDL-C的药物治疗用于以下人群的一级预防：	Ⅱa	A
●极高风险和LDL-C≥1.4 mmol/L(55 mg/dL)但 < 1.8 mmol/L(70 mg/dL)，或
●高风险和LDL-C≥1.8 mmol/L(70 mg/dL)但 < 2.6 mmol/L(100 mg/dL)，或
●中等风险且LDL-C≥2.6 mmol/L(100 mg/dL)但 < 4.9 mmol/L(190 mg/dL)，或
●低风险和LDL-C≥3.0 mmol/L(116 mg/dL)但 < 4.9 mmol/L(190 mg/dL)
同时采取最优化的非药物治疗措施，以降低CVD风险
注：DM为糖尿病(diabetes mellitus)；CKD为慢性肾脏疾病(chronic kidney disease)。

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表 4 推荐意见二：降低LDL-C的药物治疗推荐

Table 4. Recommendation 2 - Recommendations for pharmacological lowering of LDL-C

推荐内容	证据等级	证据水平
对于无法通过他汀类药物治疗来降低LDL-C水平和降低心血管事件风险的患者，推荐使用经证实具有心血管获益的非他汀类单药或联合治疗	Ⅰ	A
贝派地酸适用于无法通过他汀类药物达到LDL-C目标的患者	Ⅰ	B
对于高或极高风险患者，为达到LDL-C目标，无论是否已经使用了依折麦布，应考虑在最大耐受剂量的他汀基础上加用贝派地酸	Ⅱa	C
对于年龄≥5岁且接受最大剂量的降脂治疗，但仍未达到LDL-C目标的纯合子家族性高胆固醇血症患者，应考虑使用依维苏单抗治疗	Ⅱa	B

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表 5 推荐意见三：ACS患者降脂策略

Table 5. Recommendation 3 - Recommendations for lipid-lowering therapy in patients with acute coronary syndromes

推荐内容	证据等级	证据水平
对于入院前接受过任何降脂治疗的患者，建议在ACS住院期间启动强化降脂治疗以进一步降低LDL-C水平	Ⅰ	C
对于未接受过治疗且预计单独使用他汀类药物无法达到LDL-C目标的患者，应考虑在ACS的初始住院期间开始高强度他汀类药物联合依折麦布的联合治疗	Ⅱa	B

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表 6 推荐意见五：关于高甘油三酯血症患者药物治疗的推荐

Table 6. Recommendation 5-Recommendations for drug treatment of patients with hypertriglyceridaemia

推荐内容	证据等级	证据水平
对于甘油三酯水平升高的高风险或极高风险患者(空腹甘油三酯水平135~499 mg/dL或1.52~5.63 mmol/L)，应考虑将大剂量二十碳五烯酸乙酯(2 g/次，2次/d)与他汀类药物联合使用以降低心血管事件的风险	Ⅱa	B
对于因家族性乳糜微粒血症综合征导致严重高甘油三酯血症(750 mg/dL或>8.5 mmol/L)的患者，应考虑使用Volanesorsen(300 mg/周)以降低甘油三酯水平并减少胰腺炎风险	Ⅱa	B

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