控制糖尿病患者心血管危險的干預(yù)治療策略

1、控制糖尿病患者心血管危險控制糖尿病患者心血管危險 的干預(yù)治療策略的干預(yù)治療策略 糖尿病與心血管危險糖尿病與心血管危險 影響心血管危險的因素影響心血管危險的因素 綜合控制的理論與實踐綜合控制的理論與實踐 countries with highest numbers of estimated cases of diabetes for 2000 and 2030 rankingcountry people with diabetes (millions) country people with diabetes (millions) 20002030 1india31.7india79.4 2ch

2、ina20.8china42.3 3u.s.17.7u.s.30.3 4indonesia8.4indonesia21.3 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 chd 7-year incidence of fatal/n

3、onfatal mi (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 18.8 haffner sm et al. n engl j med 1998;339:229-234. (n=1304)(n=169)(n=890) 3.00.57.83.2 3.5 45.0 20.2 events per 100 person

4、-yr: p0.001 p0.001 type 2 diabetes and stroke 7-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-

5、234. (n=1304) (n=169)(n=890) 1.20.33.41.6 1.9 19.5 10.3 events per 100 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 dmdm/n

6、o msdm/ms % of population = 54.2%28.7%2.3%14.8% chd prevalence 1.0 0.9 0.8 0.7 0.6 0.0 0246810 follow-up, years # at risk 174214099062828935 no metabolic syndrome metabolic syndrome log-rank = 45.4 p0.001 event-free survival schillaci g. jacc. 2004; 43:1817-1822 代謝綜合征與心血管危險代謝綜合征與心血管危險 ml and microva

7、scular 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 120130 140 150160170567891011 updated mean systolic bp (mmhg)updated mean hba1c concentration

8、(%) 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和和dm患者血脂異常特征患者血脂異常特征 游離脂肪酸 tg hdl-c vldl-c 小而密ldl顆粒 氧化ldl-c 餐后高脂血癥 male gender-adjusted female reduced risk with small, dense ldl 0.1 relative risk for myocardial infarction

9、 110 increased risk with small, dense ldl small, dense ldl increases cardiovascular risk ukpds stepwise selection of risk factors* in patients with type 2 diabetes ldl-c hdl-c hemoglobin a1c systolic blood pressure smoking 0.0001 0.0001 0.0022 0.0065 0.056 coronary artery disease (n=280) first secon

10、d 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 in treating type 2 diabetes lean mej et al., diabet med, 1990;7:228-233 weight loss is difficult to maintain by diet and exerc

11、ise alone in type 2 diabetes ukpds 34. lancet 1998;352:354 insulin chlorpropamide gllbenclamide diet alone metformin weight change (kg) 7 6 5 4 3 2 1 0 -1 0246810 years from randomisation good glycemic control is not enough ukpds good glycemic control microvascular complications significant reductio

12、ns macrovascular complications no significant effect proactive study sept. 2005, 歐洲糖尿病會議歐洲糖尿病會議 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% 糖尿病患者降壓治療臨床試驗糖尿病患者降壓治療臨床試驗 shep allhat syst-

13、eur hope cappp hot nordil renaal stop-2 prime insight life ukpds major cardiovascular events (per 100 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. 30 25 20 15 10 5 0 80 85 90 90 85 80 p=0.50 for

14、trend p=0.005 for trend all hypertensive patients (n=18790) hypertensive with diabetes (n=1501) target blood pressure groups major cardiovascular events/ 1000 patients-years hot study: results in patients with dm effect of intensive vs moderate antihypertensive treatment on stroke incidence in diabe

15、tic normotensives intensivemoderate achieved bp (mmhg)128/75137/81 stroke (%)1.75.4 p = 0.03 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 lovastatin

16、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 adapted from downs jr et al. jama 1998;279:1615-1622; goldberg rb et al. circulation 1998;98:2513-2519; pyrl k et al. diabetes care 1997;20:614-620; the long-term

17、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. cards: 主要終點主要終點 年年 安慰劑組事件數(shù) 127 立普妥組事件數(shù) 83 累積危險累積危險 (%)(%) 0 5 10 15 012344.75 p=0.001 colhoun hm, betteridge dj, durrington pn, et al. lancet

18、. 2004;364:685-696. 37 trials with fibrates in patients with diabetes studyeffectp-valuecomment field study fenofibrate intervention and event lowering in diabetes mazzone t. am j cardiol 2004;93:27c-31c 糖尿病患者心血管危險因素的控制目標糖尿病患者心血管危險因素的控制目標 減輕體重 降糖: hba1c 7.0% 降壓: 130/80 調(diào)脂: ldl-c 1.81 mmol/l steno-2

19、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; 342:905-912 basic intervention 脂肪攝入30% 飽和脂肪酸攝入10% 運動 3035次/w acei or arb 多種維生素 aspirin pharmacology intervention 降糖降糖 metf

20、ormin gliclazide metformin + gliclazide 降壓降壓 thiazide acei or arb + ccb -blocker 降脂降脂 statins steno-2: treatment goals variable conventional intensive therapy therapy sbp (mmhg) 140 130 dbp (mmhg) 85 80 hba1c (%) 6.5 6.5 tc (mg/dl) 190 175 tg (mg/dl) 150 150 steno-2 change in clinical variables at the end of the study variable