控制糖尿病患者心血管危險(xiǎn)的干預(yù)治療策略課件

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