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1、Clinical Evaluation and Nonlipid Treatment of Coronary Artery Disease in the Diabetic Patient Richard Nesto, MD,Prevalence of Asymptomatic CAD in Diabetes Mellitus,Koistinen MJ. BMJ 1990;301:92-95. Type 2 Type 1 Controls Naka M et al. Am Heart J 1992;123:46-53. Type 2 Controls MiSAD Group. Am J Card
2、iol 1997;79:134-139. Type 2 Rutter MK et al. Am J Cardiol 1999;83:27-31. Type 2 w microalb Type 2 w/o microalb Le A et al. Am J Kidney Dis 1994;24:65-71. Type 1 Renal Transplant Holley JL et al. Am J Med 1991;90:563-570. Type 1 & 2 Renal Transplant,n = 64 n = 72 n = 80 n = 142 n = 149 n = 925 n = 43
3、 n = 43,Positive ETT,Positive Angiography,(thal201),36% 24% 9% 31% 30% 12.1% 65% 40% 58% 55%,9% 11% 9% 12.1% 5.3% 6.4% 35% 43%,Indications for Cardiac Testing in Diabetic Patients,Typical or atypical cardiac symptoms Resting ECG suggestive of ischemia or infarction Peripheral or carotid occlusive ar
4、terial disease Sedentary lifestyle or plan to begin a vigorous exercise program Two or more of the risk factors listed below - Total cholesterol 240 mg/dL, LDL cholesterol 160 mg/dL, or HDL cholesterol 140/90 mmHg - Smoking - Family history of premature CAD - Positive micro/macroalbuminuria,Factors
5、Limiting Accuracy of Noninvasive “Stress“ Tests for CAD,Hypertensive Cardiomyopathy Diabetic Cardiomyopathy Autonomic Cardiomyopathy Renal Insufficiency Microvascular Dysfunction,Benefits of Early Detection of CAD,Implement more aggressive CHD prevention regimen Initiate anti-ischemic medications Id
6、entify patients who would benefit from revascularization Educate patients to recognize coronary symptoms,Kannel WB et al. Am Heart J 1991;121:1268-1273.,Blood Pressure and CVD: Framingham Heart Study,Age-adjusted CV Event Rate/1,000,Systolic BP (mmHg),105,135,165,195,Systolic BP (mmHg),105,135,165,1
7、95,Age-adjusted CV Event Rate/1,000,24,50,38,77,59,119,90,174,15,31,23,48,36,74,56,113,No Glucose Intolerance Glucose Intolerance,No Glucose Intolerance Glucose Intolerance,MEN,WOMEN,UKPDS Group. Lancet 1998;352:837-853.,Effect of Glycemic Control in the UK Prospective Diabetes Study (UKPDS),Any dia
8、betes related* MI Stroke PVD Microvascular,40.9 14.7 5.6 1.1 8.6,46 17.4 5 1.6 11.4,0.029 0.052 0.52 0.15 0.0099,11 16 25,(rate/1000 pt yrs),* Combined microvascular and macrovascular events,Intensive,% Decrease,(rate/1000 pt yrs),P,Conventional,Endpoints,Reasons for Death in UKPDS Intensive Treatme
9、nt Arm: 10-Year Follow-up,UKPDS Group. Lancet 1998;352:837-853.,47%,8.7%,24%,15%,3.3%,2.5%,MI or SD,Cancer,Stroke,Other,Renal,Accidents, PVD, Hypo- & Hyperglycemia,UKPDS Group. BMJ 1998;317:703-713.,Effect of Blood Pressure Control in the UKPDS Tight vs. Less Tight Control,Any diabetes-related endpo
10、int Diabetes-related deaths Heart failure Stroke Myocardial infarction Microvascular disease,Tight Control,1,148 Type 2 patients Average BP lowered to 144/82 mmHg (controls: 154/87); 9-year follow-up,24 32 56 44 21 37,Risk Reduction (%),P value,0.0046 0.019 0.0043 0.013 NS 0.0092,UKPDS: ACE Inhibito
11、r vs. Beta-blocker for HTN Aggregate Clinical Endpoints,0.5,1,2,Relative Risk & 95% CI,Any diabetes-related endpoint Diabetes-related deaths All-cause mortality Myocardial infarction Stroke Microvascular,1.10 1.27 1.14 1.20 1.12 1.29,0.43 0.28 0.44 0.35 0.74 0.30,p,RR,UKPDS Group. BMJ 1998;317:713-7
12、20.,Favors ACE inhibitor,Favors Beta blocker,Placebo,Events / 1000 Pt-Years,Systolic Hypertension in Europe (Syst-Eur) Trial: Effect of Systolic BP Control on All Cardiovascular Events at 2 Years,Tuomilehto J et al. NEJM 1999;340: 677-684.,N=492; P=0.002,Active Rx,57.6,22.0,62% Risk Reduction,N=4,20
13、3; P=0.02,31.4,23.5,Placebo,Active Rx,25% Risk Reduction,Diabetic Patients,Nondiabetic Patients,Major CV Events,MI,Events / 1000 Pt-Years,Major Outcomes of the Hypertension Optimal Treatment (HOT) Trial: Diabetes Subgroup,Hansson L et al. Lancet 1998;351: 1755-1762.,CV Mortality,90 mmHg (N=501) 85 m
14、mHg (N=501) 80 mmHg (N=499),Diastolic Target,p0.045,p0.016,p0.005,90,Events / 1000 Pt-Years,HOT Trial:Cardiovascular Events in Diabetics and NondiabeticsEffect of Diastolic Target at 4 Years,Hansson L et al. Lancet 1998;351: 1755-1762.,Diabetic Patients n=1,501; p=0.016,85,80,90,85,80,Nondiabetic Pa
15、tients n=18,790; p=NS,24.4,18.6,11.9,9.9,10.0,9.3,48% Risk Reduction,Completed Clinical Trials with Antihypertensive Agents in Diabetes,SHEP = Systolic Hypertension in the Elderly Program; GISSI = Grupo Italiano per lo Studio della Sopravvivenza nellInfarto Miocardico; Syst-Eur = Systolic Hypertensi
16、on in Europe; HOT = Hypertension Optimal Treatment; CAPPP = Captopril Prevention Project Curb JD et al. JAMA 1996;276:1886-1892; Zuanetti G et al. Circulation 1997;96:4239-4245; Staessen JA et al. Am J Cardiol 1998;82:20R-22R; Hansson L et al. Lancet 1998;351:1755-1762;UK Prospective Diabetes Study Group. BMJ 1998;317:703-713; Hansson L et al. Lancet 1999;353:611-616.,SHEP GISSI-3 Syst-Eur HOT UKPDS CAPPP,R
