冠心病合并糖尿病患者的降脂治疗：药物选择 有何不同？

Lipid-Lowering Therapy in Patients with Coronary Artery Disease Complicated with Diabetes Mellitus: Differences in Drug Selection

摘要: 冠心病合并糖尿病患者心血管风险极高，血脂异常常呈混合型，单一降脂策略难以充分降低残余风险。本文基于循证医学证据，系统梳理了该人群中不同降脂药物的疗效、安全性及其对心血管结局的影响。他汀类药物仍为治疗基石，具有明确的降低LDL-C和心血管事件的证据；对于他汀耐受不良或达标不佳者，依折麦布和PCSK9抑制剂可作为有效补充。贝特类药物在高甘油三酯、低HDL-C亚组中可能具有潜在获益，但总体人群未显示明确心血管事件降低。GLP-1受体激动剂对心血管预后的改善主要通过减重和改善代谢状态的间接机制实现。基于患者风险分层和血脂表型，本文提出个体化降脂治疗路径，以期为临床实践提供参考。

Abstract: Patients with coronary artery disease (CAD) complicated by diabetes mellitus (DM) are at an exceptionally high cardiovascular risk. Dyslipidemia in this population is often characterized by a mixed pattern, making it difficult for any single lipid-lowering strategy to fully address the residual risk. Based on evidence-based medicine, this article systematically reviews the efficacy, safety, and impact on cardiovascular outcomes of different lipid-lowering agents in this patient group. Statins remain the cornerstone of therapy, with robust evidence supporting their role in lowering low-density lipoprotein cholesterol (LDL-C) and reducing cardiovascular events. For patients with statin intolerance or inadequate response, ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors serve as effective add-on therapies. While fibrates may offer potential benefits in the specific subgroup with hypertriglyceridemia and low high-density lipoprotein cholesterol (HDL-C), no clear reduction in cardiovascular events has been demonstrated in the overall population. The cardiovascular benefits of glucagon-like peptide-1 receptor agonists (GLP-1RAs) are primarily attributed to indirect mechanisms, such as weight loss and improvement of metabolic parameters. Based on individual patient risk stratification and lipid phenotype, this article proposes a personalized pathway for lipid-lowering therapy, aiming to provide a reference for clinical practice.