控制糖尿病患心血管危險(xiǎn)的干預(yù)治療策略

1、控制糖尿病患者心血管危險(xiǎn)控制糖尿病患者心血管危險(xiǎn)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(xiǎn)糖尿病與心血管危險(xiǎn) 影響心血管危險(xiǎn)的因素影響心血管危險(xiǎn)的因素 綜合控制的理論與實(shí)踐綜合控制的理論與實(shí)踐countries with highest numbers of estimatedcases of diabetes for 2000 and 2030rankingcountrypeople with diabetes(millions)countrypeople with diabetes(millions)200020301india31.7india79.42china20.8china

2、42.33u.s.17.7u.s.30.34indonesia8.4indonesia21.35japan6.8pakistan13.96pakistan5.2brazil11.37russian federation4.6bangladesh11.18brazil4.6japan8.99italy4.3pinecones7.810bangladesh3.2egypt16.7total: 177 million366 million by 2030type 2 diabetes and chd7-year incidence of fatal/nonfatal mi (east west st

3、udy) incidence during follow-up (%)(n=69)nondiabetics with prior minondiabetics with no prior midiabetics with prior midiabetics with no prior mi18.8haffner sm et al. n engl j med 1998;339:229-234.(n=1304)(n=169)(n=890)3.00.57.83.23.545.020.2events per100 person-yr:p0.001p0.001type 2 diabetes and st

4、roke7-year incidence of fatal/nonfatal stroke (east west study)incidence during follow-up (%)(n=69)nondiabetics with prior minondiabetics with no prior midiabetics with prior midiabetics with no prior mi7.2haffner sm et al. n engl j med 1998;339:229-234.(n=1304) (n=169)(n=890)1.20.33.41.61.919.510.3

5、events per100 person-yr:p=0.01p0.001prevalence of chd by the metabolic syndrome and diabetes in the nhanes population age 50+alexander c et al. diabetes 2003;52:1210-121425%20%15%10%5%0%no ms/no dm8.7%13.9%7.5%19.2%ms/no dmdm/no msdm/ms% of population = 54.2%28.7%2.3%14.8%chd prevalence1.00.90.80.70

6、.60.00246810follow-up, years# at risk174214099062828935no metabolic syndromemetabolic syndromelog-rank = 45.4 p0.001event-free survivalschillaci g. jacc. 2004; 43:1817-1822代謝綜合征與心血管危險(xiǎn)代謝綜合征與心血管危險(xiǎn)ml and microvascular end points: incidence bymean systolic bp and hba1c concentrationmlmicrovascular and p

7、ointsmlmicrovascular and points50403020100806040200adjusted incidence per 1000 person-yr (%)110 120130 140 150160170567891011updated mean systolic bp (mmhg)updated mean hba1c concentration (%)adjusted incidence per 1000 person-yr (%)adler al et al. bmj 2000;321:412-419stration im et al. bmj 2000;321

8、:405-412mets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malegender-adjustedfemalereduced risk with small, dense ldl0.1relative risk for myocardial infarction110increased risk with small, dense ldlsmall, dense ldl increases cardiovascular riskukpds stepwise selection of risk fac

9、tors* in patients with type 2 diabetes ldl-chdl-chemoglobin a1csystolic blood pressuresmoking0.0001 0.0001 0.0022 0.00650.056coronary artery disease (n=280)firstsecondthirdfourthfifth*adjusted for age and sex.turner rc et al. bmj 1998;316:823-828.mangaging overweight in type 2 diabeticseffective wei

10、ght management is the first step in treating type 2 diabeteslean mej et al., diabet med, 1990;7:228-233good glycemic control is not enoughukpdsgood glycemic controlmicrovascular complicationssignificant reductionsmacrovascular complicationsno significant effectproactive studysept. 2005, 歐洲糖尿病會(huì)議歐洲糖尿病

11、會(huì)議 pioglitazone vs placeboaccord studyaction to control cardiovascular risk in diabetesprisant lm. j clin pharmacol 2004; 44(4):423-430hba1c: 6.0% vs 7.0-7.9% 糖尿病患者降壓治療臨床試驗(yàn)糖尿病患者降壓治療臨床試驗(yàn) shep allhat syst-eur hope cappp hot nordil renaal stop-2 prime insight life ukpds major cardiovascular events (per

12、 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. 302520151050 80 85 90 90 85 80p=0.50 for trendp=0.005 for trendall hypertensive patients(n=18790)hypertensive with diabetes(n=1501)target blood p

13、ressure groupsmajor cardiovascular events/1000 patients-yearshot study: results in patients with dmeffect of intensive vs moderate antihypertensive treatmenton stroke incidence in diabetic normotensivesintensivemoderateachieved bp (mmhg)128/75137/81stroke (%)1.75.4p = 0.03schrier et al., kidney int

14、2002; 61:1086chd prevention trials with statins in diabetic subjects subgroup analyses primary preventionafcaps/texcapssecondary preventioncare4slipid4s-extendedlovastatinpravastatinsimvastatinpravastatinsimvastatin43%25% (p=0.05)55% (p=0.002)19%42% (p=0.001)37%23%32%25%32%239586202782483adapted fro

15、m 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 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:

16、2661-2667.trials with fibrates in patients with diabetesstudyeffectp-valuecommentfield studyfenofibrate intervention and event lowering in diabetesmazzone t. am j cardiol 2004;93:27c-31c糖尿病患者心血管危險(xiǎn)因素的控制目標(biāo)糖尿病患者心血管危險(xiǎn)因素的控制目標(biāo) 減輕體重 降糖: hba1c 7.0% 降壓: 130/80 調(diào)脂: ldl-c 1.81 mmol/lsteno-2 studymultifactorial

17、 intervention and cardiovascular disease in patients with type 2 diabetesgrade p, et al. n engl j med 2003;348:383-393steno-2: intensive therapynejm 2000; 342:905-912basic intervention脂肪攝入30%飽和脂肪酸攝入10%運(yùn)動(dòng) 3035次/wacei or arb多種維生素aspirinpharmacology intervention降糖降糖 metformin gliclazide metformin + gli

18、clazide降壓降壓 thiazide acei or arb + ccb -blocker降脂降脂 statinssteno-2: treatment goalsvariable conventional intensive therapy therapysbp (mmhg) 140 130 dbp (mmhg) 85 80 hba1c (%) 6.5 6.5tc (mg/dl) 190 175 tg (mg/dl) 150 150steno-2 change in clinical variables at the end of the studyvariable conventional intensive p therapy therapysbp