《2型糖尿病患者严格血糖控制和心血管事件的预防》由会员分享，可在线阅读，更多相关《2型糖尿病患者严格血糖控制和心血管事件的预防（56页珍藏版）》请在金锄头文库上搜索。
1、2型糖尿病患者严格血糖控制和 心血管事件的预防中山大学附属第一医院内分泌科肖 海 鹏Challenge To have patients believe in your guidance for the management of their diabetes mellitus.National Geographics (2004) AugustPrevalence of obesity increased 61% between 1991 and 2000 More than 60% of US adults are overweight Only 43% of obese persons
2、advised to lose weight during checkups BMI and weight gain major risk factors for diabetesPrevalence (%)DiabetesMean body weightkgYearMokdad et al. Diabetes Care. 2000;23:1278. Mokdad et al. JAMA. 1999;282:1519. Mokdad et al. JAMA. 2001;286:1195.Prevalence of Diabetes and ObesityGlobal prevalence of
3、 diabetes * 246 million people with diabetes worldwide = roughly 6% of the adult population In 2007, the five countries with the largest numbers of people with diabetes are: India, China, United States, Russia, Germany By 2025, the largest increases in diabetes prevalence will occur in low- and midd
4、le-income countries Each year an additional 7 million people worldwide develop diabetes* Diabetes Atlas, 3rd edition, International Diabetes Federation, 2006中国的2型糖尿病管理面临严峻的挑战“中国的糖尿病患者可能居世 界之最”“经济的迅速发展，带来了传 统生活方式的根本性变革 ，导致了中国2型糖尿病 患者的剧增。”潘长玉 301医院Diabetes complications Each year 3.8 million deaths wo
5、rldwide are attributable to diabetes Diabetes is associated with complications such as: Diabetic neuropathy Renal failure Blindness Macrovascular disease Macrovascular complications are a major cause of death in people with diabetes心血管疾病在糖尿病者中的比 率 新诊断的2型糖尿病患者25% 总糖尿病人群50% 占糖尿病死亡原因 65-75%Am Heart J 1
6、999;138:5330欧洲心脏调查结果n=2107n=2854The Euro Heart Survey on diabetes and the heart，European Heart Journal (2004) 25, 1880189043,509 例高危人群中 9,125例合并心血管疾病 OGTT 结果任一心血管事件, n=9,125NGT I-IFG IGT DM相对比例 (%)Presentation of Novartis Satellite symposium during ESC 2004,Munich,GermanyNAVIGATORGAMI:急性心梗患者中的糖代谢异 常
7、心肌梗死患者Bartnik M, et al. J Intern Med. 2004 Oct;256(4):288-97. 中国心脏调查结果-汇总 （n=3513）中华内分泌代谢杂志 2006, 22:7Risk of cardiovascular disease (CVD) in relation to HbA1c The ARIC StudyRelative Relative riskrisk of CVD of CVDn n = 1626 ( = 1626 (p p 0.001) 0.001) 5.2 5.25.2 5.2 5.7 5.75.7 5.7 6.5 6.56.5 6.5 8.
8、2 8.2 8.2 8.2 HbAHbA1c1cAjustedAjusted for age, for age, gendergender, race, smoking, BMI, , race, smoking, BMI, visceralvisceral obesityobesity, , physicalphysical activityactivity, BP and , BP and dyslipidemiadyslipidemia. .AdaptedAdapted fromfrom: : SelvinSelvin, E. , E. et collet coll. . Arch. I
9、nt. MedArch. Int. Med. 165: 1910-1916, 2005. 165: 1910-1916, 2005GAMI :新诊断高血糖 是心肌梗死后“无心血管事件存活”的预测 因素Bartnik M, et al. Eur Heart J. 2004;25(22):1990-7. 中位数随访时间:34月Diabetes patients requiring glucose-lowering therapy and non-diabetics with a prior myocardial infarctioncarry the same cardiovascular ris
10、k:A population study of 3.3 million peopleCirculation 117:1945-54, 2008All 3.3 mio Danes older than 30 years were followed from 1997 to 2002 by nation wide registersMedication treated diabetes patients and nondiabetics with and without a prior myocardial infarction were comparedAt baseline 71, 801 D
11、anes had medication treated diabetes and 79, 575 had a prior myocardial infarctionRelative Relative riskrisk for CVD for CVD mortalitymortality was 2.42 in men with diabetes mellitus without a prior myocardial infarction and 2.44 in nondiabetic men with a prior myocardial infarction (P=0.60)Hazard R
12、atioDiabetes, Glucose, and CV Disease DM is an established risk factor for CVD In DM, higher glucose levels/A1c predict higher CV riskStratton IM, et al. BMJ 2000; 321:40541212% rise per 1% rise in A1CP 10 Kg )过于严格的血糖控制目标 (HbA1c6.0%)VADT: 退伍军人2型糖尿病血糖 控制和血管并发症的研究 美国多中心研究 1791 退伍军人 (平均年龄 60.4 yrs); 97
13、%为男性强化治疗组(A1c 下降1.5%) v 标准治疗组 40% 有既往心血管病史一级终点: 主要心血管事件的发生时间 (复合终点)VADT: 结果和分析平均随访 5.6 年 A1c 6.9% A1c 在6个月内降低2% 心血管终点和死亡率上没有显 著性差异 体重增加 9 Kg 严重低血糖发生率 21.2%ADVANCE 协作组研究 2型糖尿病强化降压/降糖和血管事件结果2型糖尿病患者严格血糖控制和血管结局ADVANCE: 析因设计强化降糖组标准降糖组以达美康缓释片（格列齐特 缓释片）为起始治疗不限制其他药物的使用（磺 脲类除外）目标：HbA1c 6.5%除达美康缓释片以外的其他 磺脲类药物
14、为起始治疗 不限制其他药物的使用（磺 脲类除外）依照各地指南标准ADVANCE: 血糖结果 ADVANCE: 终点结果微血管和大血管复合终点结果主要大血管事件全因死亡微血管事件ADA 2008 Anual Meeting in SanFrancisco No positive trial effect of Intensive glucose lowering on macrovascular complications in type 2 diabetes, at least in the types of patients studiedACCORDADVANCEVADT比较: ACCOR
15、D, ADVANCE 348:2294-303DCCTEDIC：早期代谢控制的益处 颈动脉内膜厚度DCCT/EDIC Study 累积的心血管事件数欧洲糖尿病协会减少2型糖尿病心血管风险英国前瞻性糖尿病研究20年干预 研究结束后10年随访结果 (1997-2007) UKPDS 结果Mean (95%CI)UKPDS 结束10年后随访结果：HbA1c的变 化 磺脲类/胰岛素 vs. 常规治疗微血管疾病风险比强化治疗 (磺脲类/胰岛素) vs. 常规治疗(肾衰竭，玻璃体积血，光凝固法)HR (95%CI)心梗风险比(致死性或非致死性心梗或猝死) 强化治疗 (磺脲类/胰岛素) vs. 常规治疗HR
16、 (95%CI)全因死亡风险比强化治疗 (磺脲类/胰岛素) vs. 常规治疗HR (95%CI)早期血糖控制所带来的延续效应(Legacy Effect )研究结束后随访8.5年结果综合终点 19972007任何与糖尿病相关的终点RRR:12%9%P: 0.029 0.040 微血管疾病RRR: 25%24%P: 0.00990.001心梗RRR:16%15%P: 0.0520.014全因死亡RRR:6%13%P: 0.440.0071 Rury R. Holman et al, N Engl J Med. 2008 ;359(15):1618-20 RRR = Relative Risk Reduction, P = Log Rank强化治疗 (磺脲类/胰岛素) vs. 常规治疗2型糖尿病强化组长期随
