急性心肌梗死高血糖的控制.ppt

急性心肌梗死高血糖的控制,中山大学附属第一医院内分泌科肖海鹏,欧洲心脏调查结果-分组,n=2107,n=2854,TheEuroHeartSurveyondiabetesandtheheart，EuropeanHeartJournal(2019)25,18801890,GAMI:急性心梗患者中的糖代谢异常,心肌梗死患者,BartnikM,etal.JInternMed.2019Oct;256(4):288-97.,GAMI:新诊断高血糖是心肌梗死后“无心血管事件存活”的预测因素,BartnikM,etal.EurHeartJ.2019;25(22):1990-7.,中位数随访时间:34月,Diabeticswithanon-STelevationACShaveaworseoutcomethannondiabetics,IntheOASISregistryof8013patientswithanon-STelevationacutecoronarysyndrome(unstableanginaornonQ-wavemyocardialinfarction),21percenthaddiabetes.Afteratwoyearfollow-up,diabeticpatientshadasignificantlyhighercombinedeventrate(cardiovasculardeath,newmyocardialinfarction,stroke,newheartfailure)thannondiabetics(relativerisk1.56).DatafromMalmberg,K,Yusuf,S,Gerstein,HC,etal.Circulation2000;102:1014.,DiabetesincreasescoronarymortalitywithandwithoutapriorMI,Inasevenyearfollowupof1059subjectswithtype2diabetesand1378nondiabetics,diabeticswithorwithoutapriormyocardialinfarction(MI)hadagreatermortalityfromcoronarydiseasecomparedtonondiabetics(42versus16percentforthosewithapriorMIand15versus2percentforthosewithoutapriorMI.TherateofcoronarydeathandfatalandnonfatalMIindiabeticswithoutapriorMIwasthesameasinnondiabeticswithapriorMI,providingpartoftherationaleforconsideringtype2diabetesacoronaryequivalent.DatafromHaffner,SM,Lehto,S,Ronnemaa,T,etal,NEnglJMed2019;339:229.,HyperglycemiaandOutcomeAfterAcuteMI,PredictiveValueofAdmissionGlucoseFastingglucosewithin24hrsofadmissionHbA1conadmissionU-shapedcurve,Intensiveinsulintherapyreducesmortalityinpatientswithdiabetesaftermyocardialinfarction,TheDiabetesMellitus,InsulinGlucoseInfusioninAcuteMyocardialInfarction(DIGAMI)trialrandomlyassigned620diabeticpatientstoroutinecare(controlgroup)orintensivetherapywithacontinuousinsulininfusion.Afteranaveragefollowupof3.4years,themortalityinthecontrolgroupwasdirectlyrelatedtotheadmissionbloodglucoseconcentration(234mg/dL13mmol/L,234to297mg/dL13to16.5mmol/L,and297mg/dL16.5mmol/L)(p0.1,DIGAMI2result,P0.1,Why?,Copyrightrestrictionsmayapply.,Malmberg,K.etal.EurHeartJ201926:650-661;doi:10.1093/eurheartj/ehi199,Glucosecontrolexpressedasfastingbloodglucose(A)andHbA1c(B),Independentbaselinepredictorsformortality,Figure3Independentbaselinepredictorsformortality.Fastingbloodglucoserepresentsupdatedvaluesduringthetimeoffollow-up,HI-5研究,TheHyperglycemia:IntensiveInsulinInfusionInInfarction(HI-5)StudyDiabetesCare2019;29:765,HI-5研究设计,1,2,胰岛素/葡萄糖输注治疗组(ITG),HI-5结果,p=0.75,p=0.42,p=0.62,死亡率(%),HI-5结果,死亡率,HI-5研究的意义,糖尿病急性心肌梗死患者将血糖控制在144mg/dL(8.0mmol/L)是必要的。,SummaryandRecommendation,WhethercontrolofglycemiaissufficienttoreducemorbidityandmortalityarenotprovenatthistimeItwouldseemprudenttoattempttomaintainglucose10mmol/Landpossibly7.8mmol/LU-shapedrelationsuggeststhathypoglycemiashouldbestrictlyavoided,胰岛素使用方案,YaleUniversity,注意,1.该胰岛素使用草案实用于所有高血糖的ICU成年患者，而并不是单纯为糖尿病急症制定，如，糖尿病酮症酸中毒（DKA）、高血糖高渗综合征（HHS）。一旦考虑为糖尿病急症或血糖大于等于500mg/dL，应该咨询医生的意见进行特殊处理。2.如果患者对胰岛素输注的反应异常或与预期不同，或者发生任何指南没有说明的情况，应该及时通知主诊医生。任何输注胰岛素的患者都应该严密检测电介质情况，尤其是血钾的情况。,初始胰岛素使用,血糖监测,调整胰岛素输注的速度,调整胰岛素输注的速度,调整胰岛素输注的速度,*注释：停止胰岛素输注，每1530分钟复测一次血糖，当血糖大于或等于90mg/dL时，按最近胰岛素输注速度的75重新输注胰岛素。,调整