急性心肌梗死高血糖的控制.ppt

1、急性心肌梗死高血糖的控制,中山大學(xué)附屬第一醫(yī)院內(nèi)分泌科 肖 海 鵬,歐洲心臟調(diào)查結(jié)果-分組,n=2107,n=2854,The Euro Heart Survey on diabetes and the heart，European Heart Journal (2004) 25, 18801890,GAMI:急性心梗患者中的糖代謝異常,心肌梗死患者,Bartnik M, et al. J Intern Med. 2004 Oct;256(4):288-97.,GAMI :新診斷高血糖是心肌梗死后“無心血管事件存活”的預(yù)測因素,Bartnik M, et al. Eur Heart J. 20

2、04;25(22):1990-7.,中位數(shù)隨訪時間:34月,Diabetics with a non-ST elevation ACS have a worse outcome than nondiabetics,In the OASIS registry of 8013 patients with a non-ST elevation acute coronary syndrome (unstable angina or non Q-wave myocardial infarction), 21 percent had diabetes. After a two year follow-up

3、, diabetic patients had a significantly higher combined event rate (cardiovascular death, new myocardial infarction, stroke, new heart failure) than nondiabetics (relative risk 1.56). Data from Malmberg, K, Yusuf, S, Gerstein, HC, et al. Circulation 2000; 102:1014.,Diabetes increases coronary mortal

4、ity with and without a prior MI,In a seven year follow up of 1059 subjects with type 2 diabetes and 1378 nondiabetics, diabetics with or without a prior myocardial infarction (MI) had a greater mortality from coronary disease compared to nondiabetics (42 versus 16 percent for those with a prior MI a

5、nd 15 versus 2 percent for those without a prior MI. The rate of coronary death and fatal and nonfatal MI in diabetics without a prior MI was the same as in nondiabetics with a prior MI, providing part of the rationale for considering type 2 diabetes a coronary equivalent. Data from Haffner, SM, Leh

6、to, S, Ronnemaa, T, et al, N Engl J Med 1998; 339:229.,Hyperglycemia and Outcome After Acute MI,Predictive Value of Admission Glucose Fasting glucose within 24hrs of admission HbA1c on admission U-shaped curve,Intensive insulin therapy reduces mortality in patients with diabetes after myocardial inf

7、arction,The Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI) trial randomly assigned 620 diabetic patients to routine care (control group) or intensive therapy with a continuous insulin infusion. After an average followup of 3.4 years, the mortality in the control

8、group was directly related to the admission blood glucose concentration ( 234 mg/dL 13 mmol/L, 234 to 297 mg/dL 13 to 16.5 mmol/L, and 297 mg/dL 16.5 mmol/L) (p 0.001). The mortality in those treated with intensive insulin was significantly reduced (33 versus 44 percent in the control group) regardl

9、ess of the blood glucose value at admission. Data from Malmberg, K, Norhammar, A, Wedel, H, Ryden, L, Circulation 1999; 99:2626.,Relationship between admission glucose values andcrude 30-day and 1-year mortality in all patients,Admission glucose and mortality in elderly patients hospitalized with ac

10、ute MI :implications for patients with recognized diabetes Circulation 2005;111;3078,Direct comparison of risk-adjusted 30-day mortality in patients with and without recognized diabetes across range of glucose values. Adminission glucose and mortality in elderly patients hospitalized with acute MI :

11、implications for patients with recognized diabetes Circulation 2005;111;3078,30-day Mortality,One-Year Mortality,Direct comparison of risk-adjusted 1-year mortality in patients with and without recognized diabetes across range of glucose values Adminission glucose and mortality in elderly patients h

12、ospitalized with acute MI :implications for patients with recognized diabetes Circulation 2005;111;3078,Figure1:Kaplan-meier cumulative survival curves of patients with normal FG and tertiles of elevated FG,Fasting glucose is an important independent risk factor for 30-day mortality in patients with

13、 AMI :a prospective study Circulation 2005;111:754,U-shaped curve血糖水平與30天死亡率,低血糖組：11.0mmol/L U-shaped relationship of blood glucose with adverse outcomes among patients with ST-segment elevation myocardial infarction J Am Coll Cardiol 2005;46:178,U-shaped curve血糖水平與30天內(nèi)再發(fā)心?；蛩劳雎?低血糖組：11.0mmol/L U-sha

14、ped relationship of blood glucose with adverse outcomes among patients with ST-segment elevation myocardial infarction J Am Coll Cardiol 2005;46:178,Predictive value of HbA1c,Relation of chronic and acute glycemic control on mortality in acute MI with DM Am J Cardiol 2005;96:183 HbA1c on admission m

15、ay NOT independently predict mortality ,this observation suggest that stress hyperglycemia is of primary importance,Value of Glycemic Control,Cumulative survival following intensive or conventional insulin treatment in the ICU,Patients discharged alive from the ICU (panel A) and from the hospital (p

16、anel B) were considered to have survived. In both cases, the differences between the treatment groups were significant. Data from Van den Berghe, G, Wouters, P, Weekers, F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345:1359.,Diabetes Mellitus, Insulin Glucose in

17、 Acute Myocardial Infarction BMJ1997;314:1512,DIGAMI Study,DIGAMI 設(shè)計方案,標(biāo)準(zhǔn)治療組（314名） Insulin only for indication,DIGAMI: 結(jié)果,血糖水平（mg/dL ）,DIGAMI： 結(jié)果,HbA1c 的降低（%）,DIAMI研究 結(jié)果,DIGAMI: 結(jié)果,死亡率,DIGAMI2 研究,Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction Eur Heart J 2005；26：650,DIGAMI

18、-2:研究,第二組（473名） insulin iv for inpatients Standard treatment for outpatients,1,2,3,DIGAMI2 result,P 0.1,DIGAMI2 result,P 0.1,Why?,Copyright restrictions may apply.,Malmberg, K. et al. Eur Heart J 2005 26:650-661; doi:10.1093/eurheartj/ehi199,Glucose control expressed as fasting blood glucose (A) and

19、 HbA1c (B),Independent baseline predictors for mortality,Figure3 Independent baseline predictors for mortality. Fasting blood glucose represents updated values during the time of follow-up,HI-5 研究,The Hyperglycemia: Intensive Insulin Infusion In Infarction (HI-5) Study Diabetes Care 2006;29:765,HI-5 研究設(shè)計,1,2,胰島素/葡萄糖輸注治療組(ITG),HI-5 結(jié)果,p=0.75,p=0.42,p=0.62,死亡率(%),HI-5 結(jié)果,死亡率,HI-5 研究的意義,糖尿病急性心肌梗死患者將血糖控制在144mg/dL(8.0mmol/L)是必要的。,Summary and Recommendation,Whether control of glycemia is sufficient to reduce morbidity and mortality are not proven at this time It w