心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)課件

1、 心內(nèi)科醫(yī)生應(yīng)該了解的糖尿病知識(shí) 北京大學(xué)人民醫(yī)院 紀(jì)立農(nóng)心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)1 心內(nèi)科醫(yī)生應(yīng)該了解的糖尿病知識(shí) 北京大學(xué)3020100789101112123456789A.M.P.M.早餐午餐晚餐7550250基礎(chǔ)胰島素基礎(chǔ)血糖胰島素(U/mL)血糖(mg/dL)時(shí) 間健康人胰島素和血糖曲線 心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)23020100789101112123456789A.M.P-細(xì)胞的胰島素分泌調(diào)節(jié)Transport andphosphorylationGlucose-6-PGlucoseGlycolysisATP (ATP/ADP)Mitochondrialmetabolis

2、mGranule formationand traffickingDepolarizationCa2+InsulinKATPchannelGLUT2SulfonylureasSulfonylureareceptorGenetranscription心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)3-細(xì)胞的胰島素分泌調(diào)節(jié)Transport andGluco 葡萄糖在體內(nèi)的代謝心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)4 葡萄糖在體內(nèi)的胰島素抵抗肝糖生成內(nèi)源性胰島素餐后血糖空腹血糖內(nèi)源性胰島素IGT 4 7 年 “診斷糖尿病”Clinical Diabetes Volume 18, Number 2, 2000顯性糖尿病糖尿病的自

3、然病程微血管大血管心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)5胰島素抵抗肝糖生成內(nèi)源性胰島素餐后血糖空腹血糖內(nèi)源性胰島素I2型糖尿病的自然病程與血糖變化相關(guān)的其它異常糖尿病前期 糖尿病發(fā)生 并發(fā)癥出現(xiàn) 并發(fā)癥發(fā)展 殘廢 死亡胰島素抵抗失明腎衰心血管病截肢 正常血糖糖 尿 病病理基礎(chǔ)：其它異常：血脂紊亂高血壓凝血功能異常炎癥心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)62型糖尿病的自然病程與血糖變化相關(guān)的其它異常糖尿病前期 血糖紊亂與心血管病變 高血糖的分類 高血糖與心血管病變 血糖調(diào)節(jié)紊亂與心血管病變 糖尿病心血管病變 應(yīng)激性高血糖與心血管病變血糖外的因素與心血管病變 內(nèi) 容 心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)7血糖紊亂與心血管

4、病變 Reaven GM et al. Diabetologia. 1977;13:201-206.P.8r不同糖耐量狀態(tài)個(gè)體在OGTT試驗(yàn)中的血糖曲線IGT空腹血糖 150 mg/dL正常上限空腹血糖110-150 mg/dL正常Time (hr)血糖(mg/dL)01/2123400360320280240200160120801997 PPS心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)8Reaven GM et al. Diabetologia.血糖紊亂與心血管病變 高血糖的分類 高血糖與心血管病變 血糖調(diào)節(jié)紊亂與心血管病變 糖尿病心血管病變 應(yīng)激性高血糖與心血管病變血糖外的因素與心血管病變 內(nèi) 容 心

5、內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)9血糖紊亂與心血管病變 7.06.17.8 11.1FPG mmol/l2hr PPG mmol/lIGRDMNomenclature and description term defined by FPG and 2hr PPG心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)107.06.17.8 11.1FPGNomenclature and description term defined by FPG and 2hr PPGIFGIFG+IGTIGTFPG mmol/l2hr PPG mmol/l7.06.17.8 11.1DM心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)11Nomenclatu

6、re and description tNomenclature and description term defined by FPG and 2hr PPGIFHCHIFGIFG+IGTIPHIGTFPG mmol/l2hr PPG mmol/l7.06.17.8 11.1Shaw JE, et al. Diabetologia 42:1050,1999Resnick HE, et al. Diabetes Care 23:176,2000Barrett-Conner E, et al. Diabetes Care 21:1236,1998 5.6心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)12Nomen

7、clature and description t空腹和餐后血糖增高的臨床表現(xiàn) IGR(impaired glucose regulation) (impaired glucose homeostasis) (pre-diabetes)DM(diabetes mellitus)Isolated FPG IFG（少見）(impaired fasting glucose) IFH （罕見）(isolated fasting hyperglycemia)Isolated PPGIGT(impaired glucose tolerance)IPH (isolated post-challenge hy

8、perglycemia) (diabetic OGTT)FPG &PPG IFG+IGT (combined IGT)CH (combined hyperglycemia) 心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)13空腹和餐后血糖增高的臨床表現(xiàn) IGRDMIsolated 血糖紊亂與心血管病變 高血糖的分類 高血糖與心血管病變 血糖調(diào)節(jié)紊亂與心血管病變 糖尿病心血管病變 應(yīng)激性高血糖與心血管病變血糖外的因素與心血管病變 內(nèi) 容 心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)14血糖紊亂與心血管病變 Impaired glucose tolerance is a cardiovascular risk factor (Fu

9、nagata Study)Tominaga M et al. Diabetes Care 1999Cumulative cardiovascular survival1.000.980.960.940.9201234567YearSurvival rates cardiovascular diseaseNormalIFG (FPG 6.16.9mmo/L)Diabetes (FPG 7.0mmol/L)01.000.990.980.970.960.950.941234567YearSurvival rates cardiovascular diseaseNormalIGT (2h PG 7.8

10、11.0mmol/L)Diabetes (2h PG 11.1mmol/L)心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)15Impaired glucose tolerance is Paris Prospective Study 10-year follow-upEschwege E et al. Horm Metab Res 1985p0.001Coronary heart disease mortality(incidence rate/1,000)Glucose7.8mmol/L543210IGTGlucose11.1mmol/L(newly diagnosed diabetes)Knowndiabe

11、tes(n=6,055)(n=690)(n=158)(n=135)Impaired glucose tolerance progressively increases risk of coronary heart disease mortality心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)16Paris Prospective Study 10-yea心血管死亡率與餐后高血糖具有線性正相關(guān)關(guān)系Tuomilehto J. Unpublished data from DECODE4321043210患者人數(shù) (x1,000)02468101214162-hour plasma glucose (mmol/L)相

12、對(duì)危險(xiǎn)心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)17心血管死亡率與餐后高血糖具有線性正相關(guān)關(guān)系44患者人數(shù) (xCumulative hazard curves for WHO 2 h glucose criteria adjusted by age, sex, and study centre The DECODE study group THE LANCET Vol 354 August 21, 1999 619IGTnormaldiabetes心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)18 研究設(shè)計(jì)安慰劑 t.i.d. (n=715)阿卡波糖 100mg t.i.d. (n=714)1036612182430時(shí)間（

13、月）1234567891011121314就醫(yī)（次）安慰劑n=1,429Placebo60末次就醫(yī)3 個(gè)月安慰劑心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)19研究設(shè)計(jì)安慰劑 t.i.d. (n=715)阿卡波糖 100首次心血管事件的發(fā)生危險(xiǎn)下降(%) p阿卡波糖(n=682)安慰劑(n=686)患者例數(shù)有利于阿卡波糖有利于安慰劑00.51.01.52.0冠心病心梗 11291心絞痛 51255血管重建 112039心血管死亡 1 245充血性心衰腦血管意外/卒中 2 444外周血管病變 1 1 任何預(yù)先指定的心血管事件153249 0.02260.13440.18060.6298 0.50610.9255

14、0.0326心血管事件心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)20首次心血管事件的發(fā)生危險(xiǎn)下降(%) p阿卡波糖安慰劑患者例ITT累計(jì)發(fā)生率 (%)043215隨機(jī)化后時(shí)間（年）阿卡波糖安慰劑543210心血管事件發(fā)生率(僅指首次事件)心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)21ITT累計(jì)發(fā)生率 (%)043215隨機(jī)化后時(shí)間（年）阿卡波血糖紊亂與心血管病變 高血糖的分類 高血糖與心血管病變 血糖調(diào)節(jié)紊亂與心血管病變 糖尿病心血管病變 應(yīng)激性高血糖與心血管病變血糖外的因素與心血管病變 內(nèi) 容 心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)22血糖紊亂與心血管病變 糖尿病對(duì)心血管死亡率的影響心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)23 糖尿病對(duì)心血

15、管死亡率的影響心內(nèi)科醫(yī)生應(yīng)掌握美國第一次營養(yǎng)調(diào)查和二次營養(yǎng)調(diào)查冠心病死亡率的比較心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)24美國第一次營養(yǎng)調(diào)查和二次營養(yǎng)調(diào)查冠心病死亡率的比較心內(nèi)科醫(yī)生糖尿病是冠心病的等位癥012345678020406080100No diabetes and no previous MI (n = 1,304)Diabetes and no previous MI (n = 890)No diabetes and previous MI (n = 69)Diabetes and previous MI (n = 169)Survival(%)YearHaffner SM, et al.

16、 N Engl J Med 1998; 339:229234.MI: myocardial infarctionError bars indicate 95% CI心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)25糖尿病是冠心病的等位癥0123456780204060801 All other causes2型糖尿病的死因分析(Verona Diabetes Study; De Marco et al, Diabetes Care 22:756, 1999) 27.3Digestivediseases8.3Respiratorydiseases4.47.4Cardiovasculardiseases39.8Ma

17、lignanciesDiabetes12.7N=7148, 10-yr follow-up (1986-1995)心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)26 All other causes2型糖尿病的死因分析Norhammar A et al. Lancet 2002急性心肌梗塞患者的糖代謝狀態(tài) 因急性心肌梗塞而入住CCU的181例瑞典患者出院后3個(gè)月糖耐量減退和未被診斷糖尿病的比例保持不變35% 有糖耐量減退（IGT）31% 有未被診斷的糖尿病平均年齡 63.5歲此前未診斷糖尿病血糖 11.1mmol/L心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)27Norhammar A et al. Lancet 2002糖尿

18、病是心血管疾病A.H.A. Scientific Statement(Circulation 1999; 100: 1134-1146)心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)28糖尿病是心血管疾病A.H.A. Scientific Sta 大血管病變的獨(dú)立危險(xiǎn)因子（UKPDS)心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)29 大血管病變的獨(dú)立危險(xiǎn)因子（UKPDS)心內(nèi)科醫(yī)UKPDS研究中心梗與不同治療間的關(guān)系C v G v Ip = 0.66心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)30UKPDS研究中心梗與不同治療間的關(guān)系C v G v Ip血糖紊亂與心血管病變 高血糖的分類 高血糖與心血管病變 血糖調(diào)節(jié)紊亂與心血管病變 糖尿病心

19、血管病變 應(yīng)激性高血糖與心血管病變血糖外的因素與心血管病變 內(nèi) 容 心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)31血糖紊亂與心血管病變 Survival rate in women by plasma glucose quartiles 12 and 34 (P = 0.03).5.4 0.57.5 1.5Diabetes Care 24:1634-1639, 2001 Admission Plasma Glucose is An independent risk factor in nondiabetic women after coronary artery bypass grafting 心內(nèi)科醫(yī)生應(yīng)

20、掌握的糖尿病知識(shí)32Survival rate in women by plasDIGAMI Study (Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction)心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)33DIGAMI Study (Diabetes MellituSubject 620 patients with diabetes mellitus and acute myocardial infarction Intensive treatment: Standard treatment plus insul

21、in-glucose infusion for at least 24 hours followed by multidose insulin treatment (306 patients) Control: Standard treatment (314 patients)Study Design心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)34Study Design心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)34 Insulin TreatmentInsulin treatment: Intensive Control pAt discharge 266 (87%) 135 (43%) 0.00013 month 24

22、5 (80%) 141 (45%) 0.0001One year 220 (72%) 141 (49%) 0.0001 Other treatment: no difference心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)35 Insulin Treat Intensive Control PGlucose at (mmol/l) Baseline 15.7 (4.2) 15.4 (4.1) 0.4 24 h after randomisation 11.7 (4.1) 9.6 (3.3) 0.0001 Glucose at hospital discharge 9.0 (3.0) 8.2 (3.1) 0.

23、01Haemoglobin A1c (%) Baseline 8.0 (2.0) 8.2 (1.9) 0.2 3 month 1.1 ( 1.6) 0.4 (1.5) 0.0001) 12 months 0.9 (1.9) 0.4 (1.8) 5 days intensive care (long-stay patients)Long-stay ICU patients 20% risk of death in ICUHigh morbidity due to specific complications Sepsis and inflammation Multiple organ failu

24、reWasting, polyneuropathy, weaknessConsume large fraction of scarce ICU resourcesVan den Berghe G et al. N Engl J Med 2001:345:1359-1367心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)40Introduction 30% of patients Hyperglycaemia in ICUCurrent practice: Hyperglycaemia is commonCaused by insulin resistanceAdaptive? Only treated when

25、blood glucose 215 mg/dL (12 mmol/L)Key hypothesis: Hyperglycaemia (110 mg/dL, 6.1 mmol/L) predisposes to specific ICU complications, prolonged intensive care dependency, and deathVan den Berghe G et al. N Engl J Med 2001:345:1359-1367心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)41Hyperglycaemia in ICUCurrent pProspective, randomi

26、sed, controlled trialAll mechanically ventilated patients admitted to ICUConsent from closest family memberStratified for on-admission diagnosis and randomised to:Intensive insulin treatmentGlucose 110 mg/dL, maintain at 80 110 (at ICU discharge:conventional approach 200 mg/dL)Conventional insulin t

27、reatmentGlucose 215 mg/dL, maintain at 180 200心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)42Prospective, randomised, contrStudy designProtocolStandard feeding regimen started on admission Insulin by continuous i.v. infusion (syringe pump)Whole blood glucose monitored every 1 to 4 hoursInsulin dose adjusted by ICU nurses and a st

28、udy physician not involved in clinical decision makingPrimary outcome measureDeath from any cause in ICU(cause of death confirmed by autopsy-blinded pathologist)Secondary outcome measuresIn-hospital mortality Van den Berghe G et al. N Engl J Med 2001:345:1359-1367心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)43Study designProtocol

29、 Study designSecondary outcome measures: morbidityBloodstream infections*Inflammation*Acute renal failure and need for dialysis/haemofiltration*Anaemia and need for red-cell transfusions*Hyperbilirubinaemia*Critical illness polyneuropathy by weekly EMG screening*Prolonged (14 days) mechanical ventil

30、ation and ICU stayCosts (cumulative TISS)*By blinded investigators. Van den Berghe G et al. N Engl J Med 2001:345:1359-1367心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)44Study designSecondary outcome Data analysisIntention-to-treat analysisThree monthly interim analyses of primary outcome (deaths during intensive care)Study termi

31、nated for ethical reasons: significantly reduced ICU mortality at 1 year (N=1548) Van den Berghe G et al. N Engl J Med 2001:345:1359-1367心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)45Data analysisIntention-to-treaStudy population at baseline0.9Male71%71% 0.08Age (y)62146314First 24 h APACHE II score9 (713)9 (713)0.4First 24 h TI

32、SS score43 (3647)43 (3746)0.7Malignancy15%16%0.70.1BMI (kg/m2)25.84.726.24.40.9Pre-admission diabetes13%13%On-admission glycaemia 200 mg/dL12%11%0.2Conventional(n=783)Intensive(n=765)P valueInsulin treatmentNoncardiac surgery type of illness 37%38%0.8Van den Berghe G et al. N Engl J Med 2001:345:135

33、9-1367心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)46Study population at baseline0.Blood glucose controlConventionalIntensiveP value(n=783)(n=765)Patients receiving insulin39%99%0.0001Mean daily insulin dose, when given (IU/d)33710.0001Duration of insulin requirement (% ICU stay)671000.0001Insulin treatmentVan den Berghe G et al.

34、 N Engl J Med 2001:345:1359-1367心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)47Blood glucose controlConventioBlood glucose controlConventionalIntensiveDays in ICUBlood glucose (mg/dL)P 0.0001M SEMVan den Berghe G et al. Crit Care Med 2002: In press501001502000011234567891011121314152229心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)48Blood glucose controlConvent

35、ioInsulin administeredConventionalIntensive024600.10.20.30.40.50.6Units / hUnits / h per Cal / kg Days in ICUAll P 14 days*Mechanical ventilation 14 days*Dialysis / haemofiltration*Bloodstream infections*Antibiotics 10 days*Critical illness polyneuropathy46283517412944437222723* P 0.01 P 0.0001Error

36、 bars: 95% confidence intervalsVan den Berghe G et al. N Engl J Med 2001:345:1359-1367心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)54MorbidityRRR (%)020406002040NNInsulin dose or glycaemic control?Multivariate logistic regression analysis of effect on ICU mortality: (corrected for all univariate determinants of outcome) OR 95% CI

37、 P-valueDaily insulin dose : 1.006 1.0021.000 0.005(per added unit)Mean blood glucose level : 1.015 1.0091.021 150 mg/dL 5 days (N = 451)Van den Berghe G et al. Crit Care Med 2002: In press心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)56Is strict normoglycaemia essen548990125126161162197198232Blood glucose level (mg/dL)21846810121

38、416Risk of critical illness polyneuropathy (%)Rho = 1.0P 0.0001Is strict normoglycaemia essential ?Van den Berghe G et al. N Engl J Med 2001:345:1359-1367. Van den Berghe G et al. Crit Care Med 2002: In press心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)575489901251261611621971982Results summaryStrict glycaemic control 110 mg/dL w

39、ith exogenous insulinReduced ICU and hospital mortality of surgical ICU patientsReduced ICU morbidity: Severe infections and inflammationAcute renal failure and need for dialysisAnaemia and need for transfusionHyperbilirubinaemiaCritical illness polyneuropathy and prolonged ventilator dependencyProl

40、onged ICU stayVan den Berghe G et al. N Engl J Med 2001:345:1359-1367心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)58Results summaryStrict glycaemi “ 超越高血糖”2000年ADA president Speech:心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)59 “ 超越高血糖”2000年ADA pr血糖紊亂與心血管病變 高血糖的分類 高血糖與心血管病變 血糖調(diào)節(jié)紊亂與心血管病變 糖尿病心血管病變 應(yīng)激性高血糖與心血管病變血糖外的因素與心血管病變 內(nèi) 容 心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)60血糖紊亂與心血管病變 糖尿病因肥胖而始

41、并因肥胖而終 E.P. JOSLIN，1927心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)61糖尿病因肥胖而始并因肥胖而終心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)61 大血管病變的獨(dú)立危險(xiǎn)因子（UKPDS)心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)62 大血管病變的獨(dú)立危險(xiǎn)因子（UKPDS)心內(nèi)科醫(yī)各種代謝紊亂與糖尿病并發(fā)癥的相關(guān)性Am J Cardiol 2001;88(suppl):16H19H 胰島素抵抗綜合癥大血管病變微血管病變 高血糖 （細(xì)胞）血脂血壓心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)63各種代謝紊亂與糖尿病并發(fā)癥的相關(guān)性Am J Cardiol 2型糖尿病的自然病程與血糖變化相關(guān)的其它異常糖尿病前期 糖尿病發(fā)生 并發(fā)癥出現(xiàn) 并發(fā)

42、癥發(fā)展 殘廢 死亡胰島素抵抗失明腎衰心血管病截肢 正常血糖糖 尿 病病理基礎(chǔ)：其它異常：血脂紊亂高血壓凝血功能異常炎癥心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)642型糖尿病的自然病程與血糖變化相關(guān)的其它異常糖尿病前期 WHO （1999）關(guān)于代謝綜合征的工作定義基本要求：l 糖調(diào)節(jié)受損或糖尿病及/或l 胰島素抵抗（背景人群鉗夾試驗(yàn)中葡萄糖攝取率下四分位數(shù)以下）尚有下列2個(gè)或更多成份：l 動(dòng)脈壓增高140/90mmHgl 血漿甘油三酯增高1.7mmol/L及/或l 低HDL-C，男性0.9mmol/L（35mg/dl）,女性0.90，女性0.85及/或BMI30kg/m2微量白蛋白尿20微克/分或白蛋白/肌

43、肝30mg/g 心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)65 WHO （1999）關(guān)于代謝綜合征的工作定 NCEP-ATPIII確定代謝綜合征的指標(biāo)具備下列3個(gè)或更多指標(biāo)l 空腹血糖110mg/dll 血壓130/85mmHgl 甘油三酯150mg/dll HDL-C 男性40mg/dl, 女性102cm，女性88cm 心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)66 NCEP-ATPIII確定代謝綜合Cardiovascular Disease Mortality02810124605101520代謝綜合癥: 總死亡率和心血管病死亡率 Kuopio Heart Study Lokka, H-M, et al JAMA

44、2002; 288: 2709-2716All-Cause Mortality02810124605101520CumulativeHazard (%)RR indicates relative risk; CI, confidence interval. Median follow-up (range) for survivors was 11.6 (9.1-19.7) yearsNo. at RiskMetabolicSyndromeYes866852834292No288279234100Yes866852834292No288279234100Follow-up, gFollow-up

45、, gRR (85% CI)2.13 (1.64-3.61)RR (85% CI)3.55 (1.96-6.43)Metabolic SyndromeYesNoMetabolic SyndromeYesNo心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)67Cardiovascular Disease Mortali死亡四重奏 “Deadly Quartet”的影響搭橋手術(shù)后隨訪Sprecher, et al JACC 2000; 36: 1159-1165No. ofRiskFactorsMaleFemaleYears1.0Survival0.90.80.70.60.501234567891001234No.

46、ofRiskFactorsYears1.0Survival0.90.80.70.60.501234567891001234Deadly Quartet Risk Factors = obesity, diabetes, hypertension, hypertriglyceridemia心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)68死亡四重奏 “Deadly Quartet”的影響搭橋糖尿病并發(fā)癥的病因和危險(xiǎn)因素和微血管病變眼睛腎臟神經(jīng)大血管病變?nèi)毖孕呐K病中風(fēng)周圍血管病變足高血壓高血糖血脂異常凝血功能障礙吸煙 ARB2002心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)69糖尿病并發(fā)癥的病因和危險(xiǎn)因素和微血管病變大血管病變

47、足高血壓高Steno-2研究：2型糖尿病患者多因素干預(yù)與心血管疾病研究心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)70Steno-2研究：2型糖尿病患者多因素干預(yù)與心血管疾病研究Steno-2 研究目的對(duì)有微量白蛋白尿的2型糖尿病患者進(jìn)行8年多的研究，比較包括行為和藥物干預(yù)在內(nèi)的強(qiáng)化多因素達(dá)標(biāo)治療與常規(guī)治療對(duì)心血管疾病的影響心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)71Steno-2 研究目的對(duì)有微量白蛋白尿的2型糖尿病患者進(jìn)行Steno-2研究 169位有微量白蛋白尿的2型糖尿病患者9名患者因C肽6.5%, 使用口服藥當(dāng)口服藥使用至極量而HbA1c7.0%，開始使用胰島素心內(nèi)科醫(yī)生應(yīng)掌握的糖尿病知識(shí)76強(qiáng)化治療組的干預(yù)措施飲食干預(yù)：脂肪攝入量小于總熱量的30；強(qiáng)化治療組降糖藥物治療BMI25開始使用二甲雙胍（極量1g bid)開始使用格列奇特(極量160mg bid)格列奇特二甲雙胍二甲雙胍格列奇特強(qiáng)化組患者經(jīng)飲食運(yùn)動(dòng)后HbA1c6.5加用睡前NPH停二甲雙胍加用睡前NPH停格列奇特使用每日多次胰島素治療HbA1c7%HbA1c7%HbA1c7%HbA1c7%睡前NPH80U 或血糖控制不滿意心內(nèi)科醫(yī)生應(yīng)掌握