课件：糖尿病血脂治疗策略.ppt

1,北京协和医院内分泌科 肖新华,糖尿病与动脉粥样硬化 糖尿病血脂治疗策略,2,糖尿病在亚洲(2003-2025）,Number of People with Diabetes (000),Source: /prevalence/index (accessed 10/7/2005),中国糖尿病患病率近10 来源：中国糖尿病及代谢综合征流行病学调查,患病率（%）,standardized,年 龄,4,治疗模式改变,T2DM传统治疗,控制血糖,T2DM治疗新观点,降低 心血管危险,5,粥样硬化性心血管并发症,糖尿病致死、致残的主要原因,6,第64届ADA大会Banting奖得主Brownlee博士,如果糖尿病没有血管并发症，糖尿病将不再是一个重大的公共健康难题,7,Adapted from Alexander CM, Antonello S Pract Diabet 2002;21:21-28.,2/3的糖尿病患者死于CHD并发症,CHD包括冠心病，中风和外周血管疾病是糖尿病患者的主要死亡原因,67%,CHD, stroke, and peripheral vascular disease Other,糖尿病死亡原因分析,8,中国冠心病住院患者的糖代谢异常,冠心病住院患者中糖尿病患病率为52. 9% 糖调节受损患病率为24. 0% 总的糖代谢异常患病率为76. 9%,中华内分泌和代谢杂志.2006,22(1)7-10,调查包括中国7大城市共52所三级医院3513例冠心病患者,9,糖尿病：冠心病等危症,Haffner SM et al. N Engl J Med. 1998;339:229-234.,7年心梗发生率,Incidence (%),3.5,18.8,20.2,45.0,P0.001,P0.001,Nondiabetic,Diabetic,n = 1304,n = 69,n = 890,n = 169,0,10,20,30,40,50,No DM, No MI n = 1304,No DM, MI n = 69,DM, No MI n = 890,DM, MI n = 169,10,糖尿病患者中冠心病的特点,冠心病发生年龄较小1 多为无症状性、“silent”的缺血及心肌梗死2,3 通常对女性的保护作用减弱4 事实上，糖尿病妇女发生非致死性冠心病的相对风险比男性高50%,1. Wingard DL et al. In: National Diabetes Data Group, ed. Diabetes in America. Washington, DC: NIH; 1995. Publication 95-1468. 2. Wackers FJT et al. Diabetes Care. 2004;27:1954-1961. 3. Nesto RW et al. Ann Intern Med. 1988;108:170-175. 4. Huxley R et al. BMJ. 2006;332:73-78.,11,糖尿病增加CHD死亡率2-4倍,CI = confidence interval. Any heart disease, including ischemic heart disease, as underlying cause of death on death certificate. Gu K, et al. JAMA. 1999;281:1291-1297.,No Diabetes,Diabetes,心脏病死亡率,Rate per 1000 Person-Years (95% CI),糖尿病显著增加心血管疾病风险,Bell DSH. Diabetes Care. 2003;26:2433-41. Centers for Disease Control (CDC). .,2型糖尿病的心血管并发症,65%的患者死于CV,冠心病死亡 2-4倍,中风 2-4倍,心衰 2-5倍,13,对糖尿病人来说，CVD危险因子 (血糖外,主要、可治疗),高血压 异常脂血症 低密度脂肪酸 (LDL) 甘油三酯增加 1.7 mmol/l 低浓度高密度脂肪酸(HDL) 吸烟 肾损伤和蛋白尿 肥胖,14,(hepatic lipase),胰岛素抵抗与糖尿病血脂异常,Fat Cells,Liver,Kidney,Insulin,IR,X,(CETP),CE, TG Apo B VLDL,(CETP),VLDL,HDL,(lipoprotein or hepatic lipase),SD LDL,LDL,TG,Apo A-1,TG,CE,FFA,15,糖尿病血脂异常的特点脂质三联症,脂质三联症（致动脉粥样硬化血脂谱），在糖尿病患者比非糖尿病患者多见23倍。,高密度脂蛋白胆固醇（HDL-C） LDL亚型小而密LDL(SLDL)比例 甘油三脂（TG）,ADA, Diabetes Care, 2001,24 supple1, s33s43,小的LDL颗粒带来的危害,17,UKPDS：观察2693白种2型糖尿病患者中导致发生第一次心血管事件的危险因素排序,Variable Low-Density Lipoprotein Cholesterol High-Density Lipoprotein Cholesterol Hemoglobin A1c Systolic Blood Pressure Smoking,P Value 0.0001 0.0001 0.0022 0.0065 0.056,Coronary Artery Disease (n=280),Position in Model First Second Third Fourth Fifth,*Adjusted for age and sex. Turner RC et al. BMJ 1998;316:823-828.,18,冠心病危险增加的百分比(%) LDL-C 1 mmol/L 57 HDL-C 0.1 mmol/L 15 收缩压 10 mmHg 15 HbA1c 水平 1% 11 吸烟也是冠心病的主要危险因素,Adapted from Turner RC et al BMJ 1998;316:823-828.,这些数据支持在糖尿病患者中通过降低LDL-C可减少CHD危险。,在 UKPDS 中 LDL-C是糖尿病患者最强冠心病危险预测因子,19,他汀类降低冠心病事件危险性的大规模临床研究,*Cardiac death or nonfatal MI CHD, coronary heart disease; 4S, Scandinavian Simvastatin Survival Study; AFCAPS/TexCAPS, Air Force/Texas Coronary Atherosclerosis Prevention Study; ALERT, Assessment of Lescol in Renal Transplantation; ASCOT, Anglo-Scandinavian Cardiac Outcomes Trial; CARE, Cholesterol and Recurrent Events; HPS, Heart Protection Study; LIPID, Long-Term Intervention With Pravastatin in Ischaemic Disea