餐后血糖与心血管病PPT专业课件.ppt

餐后血糖与心血管病,1,.,正常人餐后状态的定义及持续时间,早餐午餐晚餐0:004:00早餐amam,8:0011:002:005:00amampmpm,Timeofbloodsamplingtoobtainadiurnalbloodglucoseprofile,餐后状态餐后吸收状态空腹状态,2,.,HbA1C=,PPG,FPG,+,3,.,餐后高血糖对HbA1c有非常大的影响,HbA1c,FBG,餐后高血糖造成的差,随机化水平,0,3,6,9,Years,4,.,Beta细胞功能下降,AdaptedfromUKPDS16:Diabetes1995:44:1249-1258,Beta细胞功能(%),自诊断的年份,UKPDS,5,.,2型DM的自然病程与-C功能的关系,-24-10030年DM,100%,IGT,6,.,胰岛素抵抗,肝葡萄糖输出,内源性胰岛素,餐后血糖,空腹血糖,内源胰岛素,IGT糖尿病,微血管并发症,大血管并发症,4-7年,“诊断为糖尿病”,糖尿病的严重性,ClinicalDiabetesVolume18,Number2,2000,7,.,2型糖尿病的三个阶段,阶段Pathophysiology指示第一阶段-胰岛素抵抗-胰岛素分泌-正常PG第二阶段-更严重的胰岛素抵抗-早期餐后胰岛素分泌受损IGT(餐后高血糖）第三阶段-严重的胰岛素抵抗-受损的胰岛素分泌-空腹高血糖-增高的内源性葡萄糖代谢-餐后高血糖1.WarramJ,etal:AnnIntemMed1990,113:909-9152.MitrakouA,etal:NEnglJMed1992,326:22-293.NinneenSF:DiabeticMed1997,14(suppl3):s19-s24,8,.,“TickingClock”(钟摆)假说,钟摆动已始于微血管并发症高血糖出现时大血管并发症发展在糖尿病前期,HaffnerSMetalJAMA1990;263:2893-2898,9,.,IMPORTANDCEOFMEALTIMEGLUCOSEEXCURSIONS,MealtimeandpostprandialhyperglycemiaaretypicallytheearliestclinicalmanifestationsofType2diabetes,Worsenspre-existingprediabeticdefectsofinsulinsecretionandaction,andcontributestooveralldailyhyperglycemia(asreflectedinHbA1c)ControlofPBGoptimizesoverallglycemiccontrol“TherapyfocusedonloweringPBG,notFBGmaybesuperiorforloweringHbA1c”(BasyretalDiabetesCare23:1236,2000)LeadstoreactivehyperinsulinemiaAssociatedwithincreasedriskformacrovascularcomplications-IGTisariskfactorforCVDcomplications-EpidemiologicstudiesshowarelationshipsbetweenPBGandriskforCVDcomplications,10,.,MealtimeGlucoseExcursionsandriskofCardiovascularDisease(1),Honoluluheartprogram,1987DiabetesInterventionStudy,1998FunagataDiabetesStudy,1999TheRanchoBernardoStudy,1998,CHDincidenceandmortalityincreasestepwisewithincreasingIGTPBG,butnotFBGisassociatedwithCHDIGT,butnotIFG,isariskfactorforCVD2-hPBGalonemorethandoublestheriskoffatalCVDandCVDinolderadults“theuseofFBGaloneforDMscreeningordiagnosismayfailtoidentifymostolderadultsathighriskforCVDandshouldbere-evaluated”,11,.,MealtimeGlucoseExcursionsandriskofCardiovascularDisease(2),ParisProspectiveStudy,1999WhitehallStudy,1999HOORNStudy,1999,DeathratesforCHDincreasing2hPBGlevelsMenintheupper2.5%ofthe2hPBGdistributionhadsignificantlyhigherCHDmortalityHighPBGlevels,especially2h-loadPBGconcentrationsandtoalesserextent,HbA1cvalues,indicateariskforCVDmortality,12,.,MealtimeGlucoseExcursionsandriskofCardiovascularDisease(3),PacificandIndianOceanPopulationStudy,1999DECODEstudy,1999TheodoraS.etal,2000,Isolated2hPBGchallengeincreasestotalmortalityandCVDmortality,andcarriesagreaterriskthanisolatedFBGCHDmortalityismorerelatedto2-hPBGthantoFPG.FPGdoesnotidentifysubjectsatriskforCHDPGandPGSaremorestronglyassociatedwithcarotidIMTthanFBGandHbA1c,13,.,Importanceofmealtimeglucoseexcursions,Mealtimeandpost-mealhyperglycemiaaretypicallytheearliestmanifestationsofType2diabetes,PBGContributestooveralldailyhyperglycemia(e.gasreflectedinHbA1candmicrovascularcomplications)PBGAssociatedwithincreasedriskformacrovascularcomplications-IGTisariskfactorforvascularcomplications-numerousepidemiologicstudiesshowarelationshipbetweenPBGlevelsandriskforcardiovascularcomplications,14,.,AdjustedSurvivalAccordingtoDiabetesCategory:PacificandIndianOceanPopulation,IFH-isolatedfastinghyperglycemia(FPG7mmol/L;2hPG11.1mmol/L)KD-knowndiabetes,KD,IPH,normal,IFH,males,J.E.Shawetal.Diabetologia1999;42:1050,15,.,血压正常的不同糖耐量患者的临床特征（1）,李春霖，潘长玉，陆菊明等中华内科杂1997;36(8):536-539,16,.,血压正常的不同糖耐量患者的动态血压改变(XSx),为昼夜差值李春霖，潘长玉，陆菊明等中华内科杂1997;36(8):536-539,17,.,组别(例)(20)(20)(20)男/女12/814/613/7年龄（岁）52.22.352.01.953.21.90.100.9007FBS(mmol/L)5.130.236.940.209.580.7222.790.0001PBS2h(mmol/L)6.370.198.650.2613.01.1323.000.0001ch(mmol/L)3.870.165.460.235.040.1717.390.0001HbA1c(%)5.390.157.420.219.790.7123.420.0001UAE(mg/L)4.17/9.12/17.4/4.260.02020.480.430.29FIns(mu/L)3.63/4.47/8.13/5.900.00730.280.350.44Ins2h(mu/L)22.4/22.9/27.5/0.270.76380.330.4200.42IAI-2.98-3.35-4.079.690.000624hSBP(mmHg)1294127213340.670.5160,NGTIGTDM2F值P值,血压正常的不同糖耐量患者的临床特征（XSx）,UAE和Ins呈偏态分布，结果用几何均数/可信因素表示，IAI为胰岛素敏感指数李春霖，潘长玉，陆菊明等中华内科杂1997;36(8):536-539,18,.,NGTIGTDM2F值P值,组别(n=)（20）（20）（20）昼SBP9219128623.540.0356夜SBP(mmHg)1084118412943.340.425DBP(%)37.16.046.45.542.05.10.690.5049SBP(%)7.12.59.92.03.72.12.310.0186MBP(%)10.02.511.22.24.32.03.270.0452,血压正常的不同糖耐量患者的动态血压改变（XSx）,李春霖，潘长玉，陆菊明等中华内科杂1997;36(8):536-539,19,.,血糖异常心电图明尼苏达编码分析检出频率例（）,*,0(0)10(96.2)18(173.1)3(28.8),32(95.2)228(543.5)256(579.5)62(176.8),6(45.8)18(137.4)15(114.5)10(76.3),11(22.5)112(229.8)128(261.8)28(57.3),15(26.9)98(176.3)113(203.2)24(43.2),Q/QS(1-X)ST压低（4-X）T波（5-X）室内阻滞（7-X),104,合计(176),NOD(131),IGT（489）,DM（556）,与血糖异常比较*0.05朱艳陆菊明等中国糖尿病杂志1997；5（1）：11-14,20,.,血糖异常合并与不合并高血压的心电图明尼苏达编码分析比较例(),与正常体重组比*0.01朱艳，陆菊明等中国糖尿病杂志1997；5（1）：11-14,21,.,血糖异常合并与不合并高血压的心电图明尼苏达编码分析比较例(),与非高血压组比*0.05朱艳，陆菊明等中国糖尿病杂志1997；5（1）：11-14,22,.,结果显示与正常糖尿病患者相比，IGT组24小时ABPM的变化具有夜间血压增高和昼夜血压差值减小的趋势，表示IGT患者已开始出现早期高血压改变,23,.,DECODE欧洲糖尿病诊断标准的流行病学调查研究,FPG（ADA诊断标准）及OGTT2hPG（WHO）诊断标准与死亡率相关性研究欧洲实施13项前瞻性研究分析对象：30岁以上25364名（男：18048，女：7316）研究开始时非糖尿病患者24089名，糖尿病患者1275名）追踪时间：7.3年累积追踪时间：男：132,785人年女：48,900人年,DECODEstudygroup:Lancet,354,617,1999,24,.,FPG及2hPG与总死亡率的相对危险度的关系,110110-125126FPG(mg/dl)年龄、性别、设施、BMI、SBP、吸烟DECODEstudygroup:Lancet,354,617,1999.TuomilehtoJ.:17thIDF,MexicoCity,November,2000,200140-200140,2hPG(mg/dl),总死亡率的相对危险度,25,.,总死亡率与2hPG的关系(DECODEstudy),4,0003,0002,0001,0000,040801201602002402803203602hPG(mg/dl)TuomilehtoJ.:17thIDF,MexlcoCity,November,2000,FDP126mg/dlr=0.71099+0.09866X,参加试验人数,26,.,总死亡率与FPG的关系(DECODEstudy),8,0006,0004,0002,0000,04080120160200240280320360FPG(mg/dl)TuomilehtoJ.:17thIDF,MexlcoCity,November,2000,2hPG180mg/dl(n=246)空腹时血糖(饭前)良好:80-110mg/dl(n=363)正常:140mg/dl(n=391)不良:140mg/dl(n=372),饭后血糖,FPG,对象：新的2型糖尿病，运动疗法的病人1139例追踪11年HanefeldM.etal.,17thIDF,MexiceCity,November,2000,心肌梗塞的发病率（千人）,33,.,餐后血糖控制不良对心血管疾病死亡影响DIS:糖尿病干预治疗,餐后血糖良好正常不良各组间差异显著,1.00.98.96生.94存.92率.90.88.86,0246810121416生存期(年)HanefeidM.etal.:17thIDF,MexicoCity,November,2000,餐后血糖累积心血管疾患死亡率追踪期间11年以上(Kaplan-Meter法),34,.,餐后高血糖、高血脂症对血管壁的影响,餐后高血糖,餐后高血脂,血管壁血管内皮细胞障碍动脉硬化HallerH.:Diab.Res.Clin.Prac.,40(Suppl),S43,1998,餐,35,.,餐后血糖/空腹血糖的持续时间,餐后,吸收后移行期,餐后,餐后,吸收后移行期,空腹时,吸收后移行期,早餐午餐晚餐0.00am4.00am早餐MonmerL.:Eur.J.Clin.Linvest.,30(Suppl.2),3,2000,36,.,Decode研究的临床意义,Source:DECODEStudyGroup.BrJMed.1998;317:371-375,Postprandialhyperglycaemia,NGT,Lowrisk,Lowrisk,Highdetection,Fastinghyperglycaemia,Highdetection,Highrisk,NFG,Lowdetection,Highrisk,37,.,DECODE:结论餐后2小时血糖（2HBG）是糖尿病死亡的独立危险因素。DECODEStudyGroup.Lancet1999;354:617-621,38,.,RAID研究的结果,AdaptedfromTemelkova-KurktschievTetal.DiabetesundStoffwechsel1998;7:227-232,*SignificantlydifferentfromhealthycontrolsandNGT*Significantlydifferentfromhealthycontrols,NGTandIGT,Healthycontrols,IGT,Type2diabetes,NGT,N=100,N=152,N=109,N=68,*,*,*,*,39,.,*,*,*,*,relativeriskofCHD,Relativerisksofcardiovasculardiseaseforimpairedglucosetoleranceanddiabetescomparedwithnormalglucosetoleranceafteradjustmentforageandsex()andforsystolicbloodpressure,bodymassindex,abnormalelectrocardiogram,totalandhigh-densitylipoproteincholesterol,smokinganddrinking().*p0.05*p0.01comparedwithnormalindividuals.FujishimaDiabetes1996;45(suppl3):514-516,RelativeRisksofCHDforNGT,IGTandDiabetes,40,.,Incidenceofmyocardialinfarction()andmortalityrate()inrelationtoqualityofcontroloffastingbloodglucosepostprandialbloodglucose,triglycerides,andbloodpressure:11-yearfollow-uptotheDiabetesInterventionStudy(DIS),*p0.05,Good,Borderline,Poor,Fastingbloodglucose,250200150100500,Good,Borderline,Poor,Postprandialbloodglucose,Rateper1000,*,*,*,*,*,*,HanefeldM.etal,DiabeticMedicine1997,14:s6-s11,餐后高血糖与心血管并发症,41,.,餐后高血糖与心血管并发症,2520151050,Rateper1000,Borderline,Triglycerides,Good,Borderline,Poor,Bloodpressure,Incidenceofmyocardialinfarction()andmortalityrate()inrelationtoqualityofcontroloffastingbloodglucosepostprandialbloodglucose,triglycerides,andbloodpressure:11-yearfollow-uptotheDiabetesInterventionStudy(DIS),*p0.05;*p0.01,HanefeldM.etal,DiabeticMedicine1997,14:s6-s11,*,*,*,*,*,*,Good,Poor,42,.,OtherstudieswhichsupporttheassociationcontinuedChineseStudy(DaQingIGT+DiabetesStudy)577IGT519controls4%IGT0.4%NGTDiabetesCare1