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1、控制糖尿病患者心血管危险的干预治疗策略,糖尿病与心血管危险 影响心血管危险的因素 综合控制的理论与实践,Countries With Highest Numbers of Estimated Cases of Diabetes for 2000 and 2030,Ranking,Country,People with diabetes (millions),Country,People with diabetes (millions),2000,2030,1India31.7India79.4 2China20.8China42.3 3U.S.17.7U.S.30.3 4Indonesia8.
2、4Indonesia21.3 5Japan6.8Pakistan13.9 6Pakistan5.2Brazil11.3 7Russian Federation4.6Bangladesh11.1 8Brazil4.6Japan8.9 9Italy4.3Pinecones7.8 10Bangladesh3.2Egypt16.7,Total: 177 million,366 MILLION BY 2030,Type 2 diabetes and CHD7-Year Incidence of Fatal/Nonfatal MI (East West Study),Incidence During Fo
3、llow-up (%),(n=69),Nondiabetics with prior MI Nondiabetics with no prior MI Diabetics with prior MI Diabetics with no prior MI,18.8,Haffner SM et al. N Engl J Med 1998;339:229-234.,(n=1304),(n=169),(n=890),3.0,0.5,7.8,3.2,3.5,45.0,20.2,Events per100 person-yr:,P0.001,p0.001,Type 2 diabetes and Strok
4、e7-Year Incidence of Fatal/Nonfatal Stroke (East West Study),Incidence During Follow-up (%),(n=69),Nondiabetics with prior MI Nondiabetics with no prior MI Diabetics with prior MI Diabetics with no prior MI,7.2,Haffner SM et al. N Engl J Med 1998;339:229-234.,(n=1304),(n=169),(n=890),1.2,0.3,3.4,1.6
5、,1.9,19.5,10.3,Events per100 person-yr:,P=0.01,p0.001,Prevalence of CHD by the Metabolic Syndrome and Diabetes in the NHANES Population Age 50+,Alexander C et al. Diabetes 2003;52:1210-1214,25%,20%,15%,10%,5%,0%,No MS/No DM,8.7%,13.9%,7.5%,19.2%,MS/No DM,DM/No MS,DM/MS,% of population = 54.2%28.7%2.
6、3%14.8%,CHD Prevalence,Schillaci G. JACC. 2004; 43:1817-1822,代谢综合征与心血管危险,Ml and Microvascular End Points: Incidence by Mean Systolic BP and HbA1c Concentration,Ml,Microvascular and points,Ml,Microvascular and points,50,40,30,20,10,0,80,60,40,20,0,Adjusted incidence per 1000 person-yr (%),110,120,130
7、,140,150,160,170,5,6,7,8,9,10,11,Updated mean systolic BP (mmHg),Updated mean HbA1c concentration (%),Adjusted incidence per 1000 person-yr (%),Adler Al et al. BMJ 2000;321:412-419,Stration IM et al. BMJ 2000;321:405-412,MetS和DM患者血脂异常特征,游离脂肪酸 TG HDL-C VLDL-C 小而密LDL颗粒 氧化LDL-C 餐后高脂血症,Male,Gender-adjus
8、ted,Female,Reduced risk with small, dense LDL,0.1,Relative risk for myocardial infarction,1,10,Increased risk with small, dense LDL,Small, dense LDL increases cardiovascular risk,UKPDS Stepwise Selection of Risk Factors* in Patients with Type 2 Diabetes,Variable LDL-C HDL-C Hemoglobin A1c Systolic B
9、lood Pressure Smoking,P Value 0.0001 0.0001 0.0022 0.0065 0.056,Coronary Artery Disease (n=280),Position in Model First Second Third Fourth Fifth,*Adjusted for age and sex. Turner RC et al. BMJ 1998;316:823-828.,Mangaging overweight in type 2 diabetics,Effective weight management is the first step i
10、n treating type 2 diabetes,Weight loss (kg) in first 12 months,Lean MEJ et al., Diabet Med, 1990;7:228-233,Good glycemic control is not enough,UKPDS,GOOD GLYCEMIC CONTROL,MICROVASCULAR COMPLICATIONS Significant reductions,MACROVASCULAR COMPLICATIONS No significant effect,PROACTIVE Study,Sept. 2005,
11、欧洲糖尿病会议,Pioglitazone vs Placebo,ACCORD Study Action to Control Cardiovascular risk in Diabetes,Prisant LM. J Clin Pharmacol 2004; 44(4):423-430,HbA1c: 6.0% vs 7.0-7.9%,糖尿病患者降压治疗临床试验, SHEP ALLHAT SYST-EUR HOPE CAPPP HOT NORDIL RENAAL STOP-2 PRIME INSIGHT LIFE UKPDS,Major cardiovascular events (per 10
12、0 patients-years) in all treated hypertensive and in hypertensive patients with diabetes in relation to target blood pressures of 90. 85, and 80 mm Hg.,HOT Study: Results in Patients with DM,Effect of Intensive vs Moderate Antihypertensive Treatment on Stroke Incidence in Diabetic Normotensives,Inte
13、nsiveModerate Achieved BP (mmHg)128/75137/81 Stroke (%)1.75.4,Schrier et al., Kidney Int 2002; 61:1086,CHD Prevention Trials with Statins in Diabetic Subjects Subgroup Analyses,Primary Prevention AFCAPS/TexCAPS Secondary Prevention CARE 4S LIPID 4S-Extended,CHD RiskReduction(overall),Drug,No.,Lovast
14、atin Pravastatin Simvastatin Pravastatin Simvastatin,43% 25% (p=0.05) 55% (p=0.002) 19% 42% (p=0.001),37% 23% 32% 25% 32%,239 586 202 782 483,CHD RiskReduction(diabetes),Study,Adapted from Downs JR et al. JAMA 1998;279:1615-1622; Goldberg RB et al. Circulation 1998;98:2513-2519; Pyrl K et al. Diabet
15、es Care 1997;20:614-620; The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. N Engl J Med 1998;339:1349-1357; Haffner SM et al. Arch Intern Med 1999;159:2661-2667.,Trials with Fibrates in Patients with Diabetes,FIELD Study Fenofibrate Intervention and Event Lowering
16、 in Diabetes,Mazzone T. Am J Cardiol 2004;93:27C-31C,糖尿病患者心血管危险因素的控制目标, 减轻体重 降糖: HbA1c 7.0% 降压: 130/80 调脂: LDL-C 1.81 mmol/L,Steno-2 Study Multifactorial Intervention and Cardiovascular Disease in Patients with Type 2 Diabetes,Grade P, et al. N ENGL J MED 2003;348:383-393,Steno-2: Intensive Therapy,NEJM 2000; 342
