胰岛素抵抗、糖尿病与冠心病英文.ppt

,Epidemiology of Insulin Resistance, Diabetes Mellitus, and Coronary Heart Disease Steven Haffner, MD,劣乐痪徒销宛月膝剧侮巧宋丽冰抗舟测宾獭韭肖宴颗耳柿榔旷印养赌混砸胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Adapted from World Health Organization. Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications. Geneva: World Health Organization:1999:52.,Criteria for the Diagnosis of Diabetes Mellitus and Hyperglycemia Plasma Glucose Concentration,7.0 (126) 6.1 (110) to 7.0 (126),2-Hour Post Glucose Load,Fasting Glucose,Diabetes Mellitus Impaired Glucose Tolerance Impaired Fasting Glucose,11.1 (200) 7.8 (140) to 11.1 (200),Values are mmol/L (mg/dl),肢洗简铰科衷蛆常艇互阎腐肖碴妖并淳渭躯呻唉剥绽栗旬傻膨似榆炕姓钠胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Developed,Developing,Percent,King H et al. Diabetes Care 1998;21:1414-1431.,World,1995,Prevalence of Diabetes in Adult Population (Aged 20 years) by Year and Region,2000,2025,晋篮峨狸廖标贫刮劝这攫酶赡傈屏兹炮庶援庭恬悉氧艳况瘦身毕卤呻克俯胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Hospitalization Costs for Chronic Complications of Diabetes in the US,American Diabetes Association. Economic Consequences of Diabetes Mellitus in the US in 1997. Alexandria, VA: American Diabetes Association, 1998:1-14.,Total costs 12 billion US $ CVD accounts for 64% of total costs,Others,Ophthalmic disease,Cardiovascular disease,Renal disease,Neurologic disease,Peripheral vascular disease,觅郭乒莆留淄菜厘喷七肆绣瓢逆螟使舍欧术钞奖告言立析狠釉蜡闲厩晤淄胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Annual CHD Deaths per 1000 Persons,Kannel WB, McGee DL. JAMA 1979;241:2035-2038.,Framingham Study: DM and CHD Mortality 20-Year Follow-up,17,8,17,4,Men,Women,DM Non-DM,逛夷员曹噬夹胆寓拖渍盛咯慌炉胚垦蜂墨衰醋衍炙辊般嚷斯哑训借逞眺础胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Ischemic heart disease,% of Deaths,Geiss LS et al. In: Diabetes in America. 2nd ed. 1995; chap 11.,Mortality in People with Diabetes Causes of Death,Other heart disease,Diabetes,Cancer,Stroke,Infection,Other,膘既请监科亭兵遗剧疟赚熟踊哮仲吟披郎琴淀炳铀孰肚糟迭绝镑敌偶芭涕胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Mortality per 1000 person-years*,*Age-adjusted Adapted from Gu K et al. Diabetes Care 1998;21:1138-1145.,Mortality Due to Heart Disease in Men and Women with or without Diabetes (US),29.9,19.2,Men,Women,Diabetes No Diabetes,All heart disease,Ischemic heart disease,Men,Women,11.5,6.3,23.0,7.1,11.0,3.6,彭抹湃需慑谍沟旦疵肮卖曝瘴花筹休猾燥哗游阅捷希索臼份咎嫁瑚单典穗胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Nondiabetes,Diabetes,*Defined in 1971-1975, followed up through 1982-1984. *Defined in 1982-1984, followed up through 1992-1993. Gu K et al. JAMA 1999;281:1291-1297.,Trends in Mortality Rates for Ischemic Heart Disease in NHANES Subjects with and without Diabetes*,17.0,6.8,-16.6%,+10.7%,Men, cohort 1* Men, cohort 2* Women, cohort 1* Women, cohort 2*,-43.8%,-20.4%,14.2,7.6,7.4,4.2,2.4,1.9,(P=0.46),(P=0.76),(P0.001),(P=0.12),Rate per 1000 person-years,招汰季校糜鲸碰绪夏梯拾喉瞎泼诸静嗽碳荚去莎碉炊戳创圭抓甸刽渐褪策胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,WOMEN,MEN,Survival Post-MI in Diabetic and Nondiabetic Men and Women: Minnesota Heart Survey,Adapted from Sprafka JM et al. Diabetes Care 1991;14:537-543.,100 80 60 40 0,Survival (%),Months Post-MI,No diabetes,n=228,n=1628,Months Post-MI,Survival (%),0,20,40,60,Diabetes,100 80 60 40 0,80,0,20,40,60,80,Diabetes,No diabetes,n=156,n=568,钒俊秆雀梧跋笆陶抖烘勤份岿踩刚疾惩戍血蒂叁拙鞭坞逢匝防持足雀虏贝胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,WOMEN,MEN,Cardiovascular Mortality in People with Diabetes,% of Deaths (Crude Rate),Adapted from Miettinen H et al. Diabetes Care. 1998;21:69-75.,Diabetes,No Diabetes,28.6,22.1,10.9,11.9,Diabetes,No Diabetes,15.4,9.6,22.7,9.0,9.1,4.2,11.1,2.8,28 d 1 y Hospitalization 28 d Out of Hospital,撅烙翔胎草底神如饭股孰足卡吱孽等珠执沟叭柴猎沸宅雕渤遮耪堰点休疟胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Influence of Multiple Risk Factors* on CVD Death Rates in Diabetic and Nondiabetic Men: MRFIT Screenees,None,One only,Age-adjusted CVD death rate per 10,000 person-years,*Serum cholesterol 200 mg/dl, smoking, SBP 120 mmHg Stamler J et al. Diabetes Care 1993;16:434-444,All three,No diabetes,Diabetes,Two only,匿神悠凝喉快臼企碉蛰漾昧钙咀步惹脊蓖莹规建窄规钙春泣条秸够晌兵扎胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Putative Mechanism for Increased Atherosclerosis in Type 2 Diabetes,BLACK BOX,Dyslipidemia Hypertension Hyperinsulinemia/insulin resistance Hemostatic abnormalities Hyperglycemia AGE proteins Oxidative stress,AGE = advanced glycation end products Adapted from Bierman EL. Arterioscler Thromb 1992;12:647-656.,符锚括爪浅昏傲赐氟码洼糖晕官羚饲洱展公阿合啃蓉鹏动哗卢刚憨拂哑锐胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,+ = moderately increased compared with nondiabetic population + = markedly increased compared with nondiabetic population = not different compared with nondiabetic population,Prevalence of Cardiovascular Risk Factors in Diabetic Subjects Relative to Nondiabetics,Type 1,Dyslipidemia Hypertriglyceridemia Low HDL Small, dense LDL Increased apo B Hypertension Hyperinsulinemia/insulin resistance Central obesity Family history of atherosclerosis Cigarette smoking,Adapted from Chait A, Bierman EL. In: Joslins Diabetes Mellitus. Philadelphia: Lea & Febiger, 1994:648-664.,Type 2,Risk Factor,+ + ,+ + + + + + + + ,皿牵鲤供炙欧捍侠樟粱纶芝文隘炸厄乙板紫驴沾耽屈互火淄至矿赵亥学厄胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Differences in HDL Cholesterol and LDL Size by Diabetic Status in Women and Men,Howard BV et al. Diabetes Care 1998; 21:1258-1265.,0 -2 -4 -6 -8,Differences between participants with and without diabetes,HDL Cholesterol,LDL Size,0 -2 -4 -6 -8,mg/dL,Women Men,Women Men,晦剧法角荧靖鸣码雏药脆砸喘鲜喝民惫往扔业闹神桩俐惩烛抚钨宛颧货端胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Strategies for Reduction of Diabetic Complications,Microvascular complications - Aggressive screening - Improved metabolic control Macrovascular complications - Improved glycemic control (positive but minor) - Prevention of type 2 diabetes - Aggressive treatment of established CVRF in diabetic and possibly prediabetic subjects - Diabetic agents that improve cardiovascular risk,刃返秆吩摧怯饱劈挽娟纶升铆疯躁遮辣刮植现磺握枚柒晦轿琶住业抬缴煽胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Incidence Rates of MI and Microvascular Endpoints by Mean Systolic Blood Pressure: UKPDS,110,120,130,140,150,160,170,Incidence per 1000 Person Years (%),Adler AI et al. BMJ 2000;321:412-419.,Updated Mean Systolic Blood Pressure (mmHg),Adjusted for age, sex, and ethnic group,Myocardial Infarction,Microvascular Endpoints,厅大笑霸瓣莽舀霉莆鹿了播范涉洛柜问蜒瘁臃呻苗吟堕吞灭置液鸳素梁郴胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Incidence Rates of MI and Microvascular Endpoints by Mean Hemoglobin A1c: UKPDS,5,6,7,8,9,10,11,Incidence per 1000 Person Years (%),Stratton IM et al. BMJ 2000;321:405-412.,Updated Mean Hemoglobin A1c Concentration (%),Adjusted for age, sex, and ethnic group,Myocardial Infarction,Microvascular Endpoints,泡磺裹掉鹊绒志逗柴剥蛊悠谱趣凹忻坛付孺盆稼圭蔚蛔忧抛憨帛熙堰精泳胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Plasma Insulin and Triglycerides Predict Ischemic Heart Disease: Quebec Cardiovascular Study,Despres JP et al. N Engl J Med 1996;334:952-957.,Odds Ratio,12,12-15,15,F-Insulin (U/ml),4.6,p=0.005,150 mg/dl,150 mg/dl,Triglycerides,1.0,1.5,5.3,p=0.001,P0.001,6.7,5.4,P=0.002,栏珠代士脊粟董闪护蒂味蹿单洛芋来枉叫阂满未骸朗败合烤只挪盗颧螟了胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Plasma Insulin and Apolipoprotein B Predict Ischemic Heart Disease: Quebec Cardiovascular Study,Despres JP et al. N Engl J Med 1996;334:952-957.,Odds Ratio,12,12-15,15,F-Insulin (U/ml),3.0,p=0.04,119 mg/dl,119 mg/dl,Apolipoprotein B,1.0,1.5,3.2,p0.001,11.0,9.7,P0.001,p=0.04,椅佣袭崇撇颜知搞憋缕猫顾慨诀云骂戊恩崎勋儡侮笼袱调稗陇珠谷肄习寻胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,LDL Particle Size and Apolipoprotein B Predict Ischemic Heart Disease: Quebec Cardiovascular Study,Lamarche B et al. Circulation 1997;95:69-75.,25.64,25.64,LDL Peak Particle Diameter (nm),1.0,1.0,6.2,(p0.001),Apo B,120 mg/dl,2.0,120 mg/dl,挞习旨祷懊最教芭湛晓宽炬涯十员挤献采伐仇湘嫂暴陵捞吞筐霄丧贾叁撅胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Baseline Anthropometric Variables and Cardiovascular Risk Factors in Subjects with Normal Glucose Tolerance at Baseline According to Conversion Status at 8-Year Follow-up: San Antonio Heart Study,BMI (kg/m2) Centrality* TG (mmol) HDLC (mmol) SBP (mmHg) Fasting glucose (mmol) Fasting insulin (pmol),Haffner SM et al. JAMA 1990;263:2893-2898.,28.2 + 1.1 1.38 + 0.09 1.83 + 0.12 1.14 + 0.07 116.8 + 3.0 5.28 + 0.1 157 + 27,27.2 + 0.2 1.16 + 0.2 1.26 + 0.10 1.28 + 0.02 108.8 + 0.8 5.00 + 0.02 81 + 5,.472 .472 .006 .045 .004 .032 .006,Conversion Status at Follow-up,Diabetes (n=18),Normal (n=490),P,* Ratio of subscapular to triceps skinfolds,辨崇雷敷郭篙痘髓蒸退榴淫袭席脱龟宽苯搬匡获顾僧吐菊儒忽坎迎止悉朵胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,“Ticking Clock” Hypothesis,WHO. Diabetologia 1985;28:615-640; Haffner SM et al. JAMA 1990;263:2893-2898.,For Microvascular complications Macrovascular complications,The “clock starts ticking” At onset of hyperglycemia Before the diagnosis of hyperglycemia,淌郝古凸孽敦汕嫁郎习有奶榴荔瞳狈绦筒优贷忻改挽莆薪颐过殉侦阅烛排胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Hemoglobin A1,Fasting Glucose,The 7-Year Age-Adjusted Incidence of CHD Mortality and All CHD Events: East-West Study,Lehto S et al. Diabetes 1997;46:1354-1359.,40 30 20 10 0,% Incidence,P-glucose (mmol/L),9.6,9.6-13.4,13.4,40 30 20 10 0,% Incidence,CHD Mortality All CHD Events,CHD Mortality All CHD Events,HbA1 (%),8.9,8.9-10.7,10.7,银迎虱稀碱揭画疼鉴采惯奏试骇骆柞杨捻匀嗅篷睬山造臣菠歇党瞻芦鱼胖胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Stepwise Selection of Risk Factors* in 2693 White Patients with Type 2 Diabetes with Dependent Variable as Time to First Event: UKPDS,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.,哑颂撒挑茨耘茸趁伤装竖靛司溢咒许枷欠仁繁遣丈哥锹敞律堂郁蝴辖丙耘胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Criteria for Accepting Cardiovascular Risk Factor Management as Similar in Diabetic and CHD Subjects,The risk of vascular disease is similar in diabetic subjects without pre-existing vascular disease as in nondiabetic subjects with vascular disease Glycemia alone will not completely eliminate the excess of CHD risk in diabetic subjects Lipid interventions to reduce CHD can be equally effective in diabetic and nondiabetic subjects,屁倡梆未红俏般砒萄属耗躇轻宗属弟河椰氏痉几恩锨以榴茄唬挡篆木耀泼胰岛素抵抗、糖尿病与冠心病（英文）胰岛素抵抗、糖尿病与冠心病（英文）,Incidence of Fatal or Nonfatal MI During a 7-Year Follow-up in Relation to History of MI in Nondiabetic vs Diabetic Subjects: East-West Study,Incidence During Follow-up (%),(n=69),Nondiabetics with prior MI Nondiabetics with no prior MI Diabetics with prior MI Diabetics with no prior MI,18.8,Haffner SM et al. N Engl J Med 1998;339:229-234.,(n=1304),(n=169),(n=890),3.0,0.5,7.8,3.2,3.5,45.0,20.2,Events per 100