2小時(shí)糖耐量試驗(yàn)的臨床意義91課件

1、2小時(shí)糖耐量試驗(yàn)的臨床意義 Finnish Academy Research Fellow芬蘭赫爾辛基大學(xué)及 國(guó)立公共衛(wèi)生研究院北大糖尿病論壇2007年 5 月12日， 北京喬青 MD, Ph.D 2小時(shí)糖耐量試驗(yàn)的臨床意義 喬青 糖尿病診斷試驗(yàn):歷史回顧糖尿病癥狀尿糖空腹血糖糖耐量 (1913年) Jacobsen A. Biochem Z 51:443, 1913糖尿病診斷試驗(yàn):歷史回顧糖尿病癥狀Jacobsen A.Normal Glucose Homeostasis Daytime Profile (N=12, health; Mean + 95%CI)Owens D ,Zinman

2、B & Bolli G : Lancet 358,739,2001Meal Times80400Insulin (mU/L)08.0013.0016.0019.00 hGlucose (mmol/L)8426Normal Glucose Homeostasis Owe2小時(shí)糖耐量試驗(yàn)的臨床意義91課件2小時(shí)糖耐量試驗(yàn)的臨床意義91課件Bimodal distribution of glucoseand prevalence of retinopathy and proteinuria in Pima Indians Knowler WC etc. Diabetes Metab Rev 6: 1

3、-27, 1990Bimodal distribution of glucosCopyright 1994 BMJ Publishing Group Ltd.McCane, D R et al. BMJ 1994;308:1323-85 year cumulative incidence (top) and prevalence (bottom) of retinopathy in relation to tenths of 2hPG, FPG, and HBa1c Copyright 1994 BMJ Publishing現(xiàn)用診斷標(biāo)準(zhǔn)NDDG1979: FPG=7.8 mmol/l and

4、75g OGTT at , 1, 1, 2 hours WHO 1980: adopted the NDDG criteria, 2h glucose=11.1 mmol/l after 75g load as “金標(biāo)準(zhǔn)”WHO 1985: slightly modified the WHO 1980 criteriaADA 1997: FPG 7.8 mmol/l to 7.0 mmol/l，Not use OGTTWHO 1999: adopted the FPG 7.0 mmol/l, retained the 2h OGTTWHO/IDF 2006: no changes except

5、 for some terms 現(xiàn)用診斷標(biāo)準(zhǔn)NDDG1979: FPG=7.8 mmol/什么是糖耐量異常?1. 均值+2標(biāo)準(zhǔn)差2. 血糖雙峰分布,小血管病變3.大血管病變: 心腦血管及外周血管病變 什么是糖耐量異常?1. 均值+2標(biāo)準(zhǔn)差Dysglycemia Normoglycemia in Acute and Stable CV DiseaseConsecutive pts: 2107 in-pts; 2854 out-pt elective CV consults in Europe (71% men; mean age 66) OGTT/old DM in 1587 (75%) acu

6、te & 1857 (66%) elective pts before discharge or within 2 mo. Euro Heart SurveyBartnik M et al; Eur Ht J 2004;1880NGTIFGIGTKnown DMNew DM29%35%22%22%31%30%15%10%3%3%020406080100%AcuteElectiveDysglycemia Normoglycemia iThe DECODE Study (http:/www.ktl.fi/decode/index.html)Diabetes Epidemiology: Collab

7、orative analysis Of Diagnostic criteria in Europe The DECODE Study (http:/www.k 2-hour plasma glucose (mmol/l)7.87.811.011.1Total21,9682,0202,56289331620624,8463,1197.02763784891,143Fastingplasmaglucose(mmol/l)Total24,2643,8331,01129,108Adapted from DECODE Study Group. Br Med J 1998;317:371

8、375 Classification of individuals - the DECODE Study 2-hour plasma glucose (mmoDiscrepancy of FPG and 2hPG criteria in the DECODA study Diabetologia 2000; 43: 1470-1475Discrepancy of FPG and 2hPG cr 30-39 40-49 50-59 60-69 70-79 80-89Prevalence (%) of newly diagnosed DM in DECODE populationsThe DECO

9、DE group, Diabetes Care 2003; 26: 61-69. 30-39 30-39 40-49 50-59 60-69 70-79 80-89 Prevalence (%) of IGT but not IFG increases with age in DECODE populationThe DECODE group, Diabetes Care 2003; 26: 61-69. 30-39 40-Hazards ratio for all-cause mortality in subjects without prior history of diabetes Ad

10、j. for age, cohorts, sex, chol, BMI, SBP, smoking 2-hour plasma glucose(mmol/l)7.0 11.17.811.07.8Fasting plasma glucose (mmol/l)2.52.01.51.00.50.0Hazard ratioAdapted from DECODE Study Group, Lancet 1999;354:617621Hazards ratio for all-cause moAll-cause mortality has a linear relationship wi

11、th 2-hour plasma glucoseDECODE, Diabetes Care 2003; 26: 688-696All-cause mortality has a lineCVD mortality by 2-hour plasma glucoseFrequencyHazard ratioDECODE, Diabetes Care 26: 688-696CVD mortality by 2-hour plasmaCVD mortality by fasting plasma glucoseFrequencyHazard ratioDECODE, Diabetes Care 26:

12、 688-696CVD mortality by fasting plasmHazard ratio for mortality by FPG categories, the DECODA StudyFPG (mmol/l)6.1(n=5547)6.1-6.9(n=462)7.0(n=297)P for trendCVDModel 1Model 2111.4 (0.9-2.1)1.1 (0.7-1.7)2.0 (1.3-3.1)0.9 (0.5-1.5)0.0060.83All-causeModel 1Model 2111.2 (0.9-1.6)0.9 (0.7-1.3)1.8 (1.3-2.

13、5)0.9 (0.6-1.3)0.0010.81Model 1: Adjusted for age, sex, cohort, BMI, sysBP, Chol and smokingModel 2: Additional adjustment for 2hPG DECODA Study Group, Diabetologia 2004; 47: 385-394Hazard ratio for mortality by Hazard ratio for mortality by 2hPG categories, the DECODA Study2hPG (mmol/l)7.8(n=4753)7

14、.8-11.0(n=1106)11.1(n=447)P for trendCVDModel 1Model 2111.3 (0.9-1.9)1.3 (0.9-1.9)3.2 (2.2-4.7)3.4 (2.1-5.4)0.0010.001All-causeModel 1Model 2111.3 (1.0-1.7)1.4 (1.0-1.8)2.9 (2.2-3.8)3.0 (2.2-4.2)0.0010.001Model 1: Adjusted for age, sex, cohort, BMI, sysBP, Chol and smokingModel 2: Additional adjustm

15、ent for FPG DECODA Study Group, Diabetologia 2004; 47: 385-394Hazard ratio for mortality by Non-diabetic DiabeticFollow-upBaseline 2hPGNGTIGTNon-diabeticCHD incidence 5.39.716.1CVD mortalityAll-cause mortality7.612.815.5Incidence density (no./per 1000 person-years)Qiao et al. Diabetes Care

16、2003; 26:2910-2914Non-diabetic DiabeticFollow-upHazard ratio (95% CI) by glucose status at baseline and at follow-upFollow-upNon-diabeticDiabeticBaseline 2hPGNGTIGTNon-diabeticCHD incidence11.5 (1.0-2.3)1.8 (1.0-3.2)CVD mortality12.3 (1.4-3.9)1.7 (0.8-3.5)All-cause mortality11.7 (1.1-2.4)1.5 (0.9-2.

17、5)Adjusted for age, sex, WHR, SBP, Chol, HDL and smokingQiao et al. Diabetes Care 2003; 26:2910-2914Hazard ratio (95% CI) by glucoEffect of intensive glycemic control on the risk for any type of macrovascular eventsC Stettler, Am Heart J 2006; 152:27-38Effect of intensive glycemic cSTOP-NIDDM Trial

18、(1)Myocardial infarctionAnginaRevascularization procedureCardiovascular deathCerebrovascular event or strokePeripheral vascular diseaseAny cardiovascular event FavoursAcarboseFavoursPlaceboChiasson JL JAMA 2003; 23: 290:486-94STOP-NIDDM Trial (1)MyocardialThe main changes from baseline to 3 years:Ac

19、arbosePlaceboSTOP-NIDDM Trial (3)Body Weight (kg) -1.15 0.26BMI (kg/m2) -0.60 -0.12Waist (cm) -0.62 0.17SysBP (mmHg) -0.97 -0.05DiasBP (mmHg) -2.8 -1.42hPG (mmol/L) -0.63 0.04Triglycerides (mmol/L) -0.18 -0.04All p 50 conventional pts - CV event 11 yrs post DCCT; 17 yrs altogetherGHb Results: DCCT E

20、ndEDIC EndIntensive7.4 (1.1)7.9 (1.3)Conventional9.1 (1.5)7.8 (1.3)Intensive Insulin Rx & CVD: T1Intensive Insulin Rx & CVD: T1 DM DCCT/EDIC NEJM 2005;353:2643Primary CV CompositeRRR= 42% (9-63)RRR after adj. for updated GHb until end of DCCT (or CV event during DCCT): 16% (-64 57) P=0.61Intensive I

21、nsulin Rx & CVD: T1Intensive Insulin Rx & CVD: T1 DM DCCT/EDIC NEJM 2005;353:2643MI, Stroke, CV DeathRRR= 57% (12-79)Intensive Insulin Rx & CVD: T1Chronic G Lowering & CVD: IGT STOP NIDDM Analysis: Chiasson et al. JAMA 2003;290:486HR 0.51 (0.28-0.95)(i.e. 32/686 vs. 15/682 MI, Angina, Revasc, CV Dea

22、th, CHF, Stroke, or PVD)Chronic G Lowering & CVD: IGT Copyright 1994 BMJ Publishing Group Ltd.McCane, D R et al. BMJ 1994;308:1323-8ROC curves for prevalence of retinopathy (top) and nephropathy (bottom) for 2hPG (-), FPG (.), and HbA1 (-) concentrations1-SpecificityCopyright 1994 BMJ PublishingRela

23、tive risk (95% CI) of mortality significantly increased in subjects with IGTMultivariate adjusted: for age, center, sex, cholesterol, BMI, BP, smokingMortalityRR, multivariateadjustedRR, adjustedalso for FPGCVD1.34 (1.14-1.57)1.32 (1.12-1.56)CHD1.28 (1.02-1.59)1.27 (1.03-1.58)Stroke1.26 (0.88-1.80)1

24、.21 (0.84-1.74)All-cause1.40 (1.27-1.54)1.37 (1.25-1.51)The DECODE group, Arch Intern Med 2001; 161:397-404Relative risk (95% CI) of mortHazards ratio for mortality in diabetic patients according to FPG The DECODE group, Arch Intern Med 2001; 161:397-404Adjusted for age, center, sex, cholesterol, BM

25、I, BP, smoking Hazards ratio for mortality inHazards ratio for mortality in diabetic patients according to 2-hour glucose The DECODE group, Arch Intern Med 2001; 161:397-404Adjusted for age, center, sex, cholesterol, BMI, BP, smoking Hazards ratio for mortality inTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z

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