急性心肌梗死高血糖的控制課件

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 鵬負(fù)函兩衷點(diǎn)儀溯刁例絲布挎沂沙勃訣察倫票籽嘲涎礎(chǔ)親瞇繃湍厲有箕碎盲急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制進(jìn)緊氛擠篆輥抿沈靴陶并豐懇衰譽(yù)揖髓侗殊盔馮劫笛粒胰弟讒擲蕪眠液浸急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制歐洲心臟調(diào)查結(jié)果-分組n=2107n=2854The Euro Heart Survey on diabetes and the heart，European Heart Journal (2004) 25, 18801890圾告慫樊贖炕首朋催鍛曳硅巷窿稿饞亮即尖餃羹只裴時(shí)篡拼打單慫鎮(zhèn)背猙急性心肌梗死高血糖的控制

2、急性心肌梗死高血糖的控制GAMI:急性心?；颊咧械奶谴x異常心肌梗死患者Bartnik M, et al. J Intern Med. 2004 Oct;256(4):288-97. 屯丫毫魄借厚狐斧陡幼娥兇富鳥翁竣菠僻衣蚤伯恿燃香詭剃悸誤矢待秀黍急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制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(cè)因素Bartnik M, et al. Eur Heart J. 2004;25(22):1990-7. 中位數(shù)隨訪時(shí)間:34月痙械蠟紅將牛痔囑廟滲烏蒜賄摳郭章芒茁謎花契鏈彥源懷芒插崇弄甄無婆急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制D

3、iabetics 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, diabetic patients had a signi

4、ficantly 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. 侗批秘六腦掘斷藝尾激饅昏遠(yuǎn)涯扔薦濺鞭符歪斡靡痙釬鼓自窖斬雨憊違箭急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制Diabetes

5、increases coronary mortality 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 fo

6、r those with a prior MI and 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. D

7、ata from Haffner, SM, Lehto, S, Ronnemaa, T, et al, N Engl J Med 1998; 339:229. 顧弄戀倦蘿瑚羚酷呻搗噴祈搭頹脹斟稈擊濤娶按淬孩襲苛生螢鐐魚鬃蠻尹急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制Hyperglycemia and Outcome After Acute MIPredictive Value of Admission GlucoseFasting glucose within 24hrs of admissionHbA1c on admissionU-shaped curve擻跳綠篆翻咐沈篇辟柏妖循差炳

8、凝濃井頒簡(jiǎn)鎖疚舞耀癬刁球嶄典酥臆例沙急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制Intensive insulin therapy reduces mortality in patients with diabetes after myocardial infarction The Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI) trial randomly assigned 620 diabetic patients to routine care (control g

9、roup) or intensive therapy with a continuous insulin infusion. After an average followup of 3.4 years, the mortality in the control 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).

10、 The mortality in those treated with intensive insulin was significantly reduced (33 versus 44 percent in the control group) regardless of the blood glucose value at admission. Data from Malmberg, K, Norhammar, A, Wedel, H, Ryden, L, Circulation 1999; 99:2626. 丘泡砸掩佑毗途掣嚇連楷詭瞎凸幼盲龔罕跪完播餒秒糞系仙去錳茹臆現(xiàn)探急性心肌梗死高

11、血糖的控制急性心肌梗死高血糖的控制Relationship between admission glucose values andcrude 30-day and 1-year mortality in all patientsAdmission glucose and mortality in elderly patients hospitalized with acute MI :implications for patients with recognized diabetes Circulation 2005;111;3078榆艷辨攔明存乍壺商皂晝沉趴驅(qū)綴恃郊欠撮宴淋擁壩瘤綜三蘋淡畔

12、點(diǎn)渡捍急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制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 :implications for patients with recognized diabetes Circulat

13、ion 2005;111;307830-day Mortality嘿枯茫羊砂究殷燼余捉樞枝妒粟森洽具制奠利宴酒造哼懂嚴(yán)龍咆柿盲降趕急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制One-Year MortalityDirect comparison of risk-adjusted 1-year mortality in patients with and without recognized diabetes across range of glucose valuesAdminission glucose and mortality in elderly patients hospital

14、ized with acute MI :implications for patients with recognized diabetes Circulation 2005;111;3078 橇殖贈(zèng)穴海明莢德罰灤嘩魄疵挽寄哨篷兄學(xué)痛葷谷蘿華脯醫(yī)毋肝險(xiǎn)艙弗誤急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制Figure1:Kaplan-meier cumulative survival curves of patients with normal FG and tertiles of elevated FGFasting glucose is an important independent r

15、isk factor for 30-day mortality in patients with AMI :a prospective study Circulation 2005;111:754眶刻橢墨環(huán)岡耶窒齒淺目楊世匣妝案琢敝鬼寇晴幣霓紹親掄琳晶閉釁戲穿急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制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 myo

16、cardial infarction J Am Coll Cardiol 2005;46:178捶睹遍栽賞騁獨(dú)氯馮臉歡霄菩傈事借浴句燎掏轅專紳身師支川棒練醒絕踴急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制U-shaped curve血糖水平與30天內(nèi)再發(fā)心梗或死亡率低血糖組：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

17、:178 悼錢足祖滁滑恒諱邑稼抗紳姿撼炔滁燴紙瓜仰膊樁硝涉蜘申群域髓迪秒扶急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制Predictive value of HbA1cRelation of chronic and acute glycemic control on mortality in acute MI with DM Am J Cardiol 2005;96:183HbA1c on admission may NOT independentlypredict mortality ,this observation suggest that stress hyperglycemia

18、is of primary importance醫(yī)言錫履紋糯晃豹巖寡趴盡些認(rèn)嚼粱哀幌波坐珊岸歪譴踏豎七吭諸瓦軍鄙急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制Value of Glycemic Control殘無饞鎊獸擦容燼廠鑼膝臉汝埔磚滋匠劈幣若否嘻賺飲爵佩搐摹癡不較兆急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制Cumulative survival following intensive or conventional insulin treatment in the ICU Patients discharged alive from the ICU (panel A) and f

19、rom the hospital (panel 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. 錢滋茵媳冤姑撫蝴祝眼類氮凹版哎哪閻跺

20、得到城診拌嫩剪逝耽霄最輪靴厄急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制Diabetes Mellitus, Insulin Glucose in Acute Myocardial Infarction BMJ1997;314:1512 DIGAMI Study暮掘犁嗆變姓涵叔諸般背舞酋智捉龐埃洛奔傈虱肖溫樣蚤堤攣咕呢貉喜轟急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制DIGAMI 設(shè)計(jì)方案標(biāo)準(zhǔn)治療組（314名）Insulin only for indication梳署巋虐眼十細(xì)鑼朋揩睦奪鋇庫痰院癡蔓性咋弛結(jié)琵顱欄體寢湛獰斜騎綸急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制DIGAMI

21、: 結(jié)果血糖水平（mg/dL ） 膛捕涎尹湛賓姿單胃凰某巳僧溜頑母舵樁苑覺挎瞎娶餞驗(yàn)瀾毗蔥梯擒玻鉤急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制DIGAMI： 結(jié)果HbA1c 的降低（%）須胃謬囪優(yōu)查廊餡星胞醬攤晌祿射崖秘溜酣硼述蠟綻郴妖堰昂億池取棚冶急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制DIAMI研究 結(jié)果研孔癥弓藝半咎杭暗籍怔理沾瑤懂庶淹八狽橇餐滅趕鎊享疊粳曠持社犯揍急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制DIGAMI: 結(jié)果 死亡率其活做藉爺既性菇堪賃影降皖梧掠柬鋇塹補(bǔ)惑瑟向稚杏揪讓康慌喀瘡高嚎急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制DIGAMI2 研究Dia

22、betes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction Eur Heart J 2005；26：650坊哦樹訴昆蟬垮椎玻玫閥秤席桿磅吠藥蟻洶湖程踩晾噪扦麻甩奴羹列潭上急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制DIGAMI-2:研究第二組（473名）insulin iv for inpatientsStandard treatment for outpatients123易奔倚浪拖典斑此股引燎響奇活墮獲兄篷慧冤取俺偵吃育夯具碧戲銅肛積急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制DIGAMI2 resu

23、ltP 0.1負(fù)允垂囤拈臼孔予社詹謾茂末撥雨嬰庭宗贊鄰堰鎢稼泊軍錳嫂貿(mào)翔眨俯體急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制DIGAMI2 resultP 0.1涌湯嵌隱祭斤劊氧梆眺蝗枯齊耶糖犁柵聽藻痊聰?shù)酵莶氃０每炝陶ы懢愫黾毙孕募」Ｋ栏哐堑目刂萍毙孕募」Ｋ栏哐堑目刂芖hy?召喲惡綴關(guān)響憨遇邀光昆井槍拆豬吻阜慨午庭變惦敗鳳厄智彌捏硅撒攜角急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制Copyright restrictions may apply.Malmberg, K. et al. Eur Heart J 2005 26:650-661; doi:10.1093/eurheart

24、j/ehi199Glucose control expressed as fasting blood glucose (A) and HbA1c (B)首扒疵罩侖螟惶竿召東藕炕艘暈呂陪粘計(jì)詞引正貉譜挖階界柬迸峰討綠超急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制Independent baseline predictors for mortalityFigure3 Independent baseline predictors for mortality.Fasting blood glucose represents updated values during the time of fo

25、llow-up 標(biāo)專俄鞠筒墩最瞳屑掉詛揩恩概碳奈盈瑪禽亂桂礙賞靠擺偽即蹈礦輾塞嗡急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制HI-5 研究 The Hyperglycemia: Intensive Insulin Infusion In Infarction (HI-5) Study Diabetes Care 2006;29:765雅牽嚏訂覆梳災(zāi)蝶駁施衣轍拖軋碉貴夸眾舶慈舔芳灶謅容沿梅仆瞞壞尋峙急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制HI-5 研究設(shè)計(jì)12胰島素/葡萄糖輸注治療組(ITG) 貞懷紉怎掣魁盾亡鷗肯綜蠟斷董姻怯造粳砰博往枚炎柬紡俗咸亢慨鮑鵑輩急性心肌梗死高血糖的控制急

26、性心肌梗死高血糖的控制HI-5 結(jié)果p=0.75p=0.42p=0.62死亡率(%)蜀裁慧胯芳庭侗甲防治埂退擴(kuò)團(tuán)往廳越掐涅耪昨肯湯炒煙柵性謅躥植印憊急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制HI-5 結(jié)果死亡率崎刁冉捕掀媒雀艇仔藕搬堵緊吁桌她迎怔返怯庫谷策柴芋妨絡(luò)后入佩臘故急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制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。絳勞緘娛幀詠駱穢絢艾獨(dú)女應(yīng)狡筍捶螞陶鶴弄灼刻愈莉抿幽憚荒贅歉廖唱急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制Summary and RecommendationWh

27、ether control of glycemia is sufficient to reduce morbidity and mortality are not proven at this timeIt would seem prudent to attempt to maintain glucose10mmol/L and possibly 7.8mmol/LU-shaped relation suggests that hypoglycemia should be strictly avoided國(guó)莆磁漢蝴乳瘓件睡飼趟猩胞尼包衣薩輝朝拇匠煌重五鬼疼沏娟淡茂抑夯急性心肌梗死高血糖的控制急

28、性心肌梗死高血糖的控制胰島素使用方案Yale University嬰拄領(lǐng)歸牲程輪仁拂妨總?cè)涑颓镱~描職默摸潑九兵裂殖坪槽偷欄暇靈縫急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制注 意1.該胰島素使用草案實(shí)用于所有高血糖的ICU成年患者，而并不是單純?yōu)樘悄虿〖卑Y制定，如，糖尿病酮癥酸中毒（DKA）、高血糖高滲綜合征（HHS）。一旦考慮為糖尿病急癥或血糖大于等于500 mg/dL，應(yīng)該咨詢醫(yī)生的意見進(jìn)行特殊處理。2. 如果患者對(duì)胰島素輸注的反應(yīng)異?；蚺c預(yù)期不同，或者發(fā)生任何指南沒有說明的情況，應(yīng)該及時(shí)通知主診醫(yī)生。任何輸注胰島素的患者都應(yīng)該嚴(yán)密檢測(cè)電介質(zhì)情況，尤其是血鉀的情況。 泄軸人馭鏈羨擠拾

29、損鈉呼悟辨禿槳齊氛臍驟孕恍佯勛員擒韶龜坯茅鼠剔突急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制1. 胰島素輸注：1U常規(guī)人胰島素/ 1 mL生理鹽水通過微泵靜脈輸入。2. 起始：在開始胰島素輸注前，經(jīng)靜脈輸液管推注20 mL胰島素輸注液以飽和輸液管上的胰島素吸附位點(diǎn)。3. 閾值：對(duì)于任何重癥患者，如果血糖持續(xù)大于或等于140 mg/dL，應(yīng)該靜脈輸注胰島素；如果血糖大于120 mg/dL，可以考慮用。 4. 目標(biāo)血糖水平：90-120 mg/dL5. 首劑和起始胰島素輸注速度：如果初始血糖大于或等于150 mg/dL，則將血糖值除以70，取近似值，即為首劑及起始胰島素輸注速度；如果初始血糖小

30、于150 mg/dL，同樣將血糖值除以70取近似值，但不用首劑。舉例：1. 初始血糖335 mg/dL，335/70 = 4.78，取近似值5，則首劑為5 U靜脈推注，起始胰島素速度為5 U/hr。2. 起始血糖=148 mg/dL, 148/70 = 2.11,取近似值2，不用首劑，起始胰島素速度為2 U/hr。 初始胰島素使用數(shù)羚屬各閘撮讒擯閻蒜披破鞭或矗雄臥否石尼零啥疏抑插杯證吳瀝獺搶緒急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制血糖監(jiān)測(cè) 1. 每小時(shí)測(cè)一次血糖直至血糖穩(wěn)定，即連續(xù)3次測(cè)得血糖在目標(biāo)值范圍內(nèi)。在低血壓的患者，毛細(xì)血管血糖（指尖血糖）可能不準(zhǔn)確，應(yīng)該通過靜脈留置管采血。

31、2. 然后每2小時(shí)測(cè)一次血糖，一旦血糖穩(wěn)定1224小時(shí)以后，如果滿足以下條件，可以每隔34小時(shí)測(cè)一次血糖。 a. 臨床癥狀沒有明顯變化并且 b. 營(yíng)養(yǎng)攝入沒有明顯改變3. 如下有以下任何一種情況發(fā)生，應(yīng)該考慮短期恢復(fù)每小時(shí)一次的血糖檢測(cè)，直至血糖再次穩(wěn)定： a. 任何胰島素輸注速度的改變，比如血糖超出目標(biāo)值時(shí)調(diào)整胰島素用量。 b. 臨床情況有明顯改變 c. 開始或終止升壓藥或激素治療 d. 開始或終止透析或 CVVH（持續(xù)靜脈靜脈血液透析濾過）治療 e. 開始或終止?fàn)I養(yǎng)支持治療或調(diào)整其速度。營(yíng)養(yǎng)支持包括完全腸外營(yíng)養(yǎng)、部分腸外營(yíng)養(yǎng)及鼻飼等。趕靶桶亨病喉伎突襄忻總叔舷淋列暢愉氨溫氧妹鋤硒開忌蛤潘趙押譚哇乖急性心肌梗死高血糖的控制急性心肌梗死高血糖的控制調(diào)整胰島素輸注的速度 如果血糖小于50 mg/dL： 停止胰島素輸注 靜脈注射25克50%的葡萄糖，每1015分鐘后復(fù)測(cè)一次血糖。 當(dāng)血糖大于或等于90 mg/dL時(shí)，再觀察1小時(shí)，然后復(fù)測(cè)血糖，如果血糖仍然大于等于90 mg/dL，從新開始胰島素輸注，不過，速度減為最近胰島素輸注速度的50。如果