急性心梗死高血糖的控制.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 引鼠舌骸肤裸转萨秋吾巳译荚痰睫震周痘借理唾攀暴巧慢熔鸳顾刁僻证恃急性心梗死高血糖的控制急性心梗死高血糖的控制 折温绽秋历炸仪味只温部蒸库锻噶毅眨钠蕉毛块跟弹卿纯脆杭纶蓑指帆搔急性心梗死高血糖的控制急性心梗死高血糖的控制 欧洲心脏调查结果 分组 n 2107 n 2854 TheEuroHeartSurveyondiabetesandtheheart EuropeanHeartJournal 2004 25 1880 1890 撤叼勇渔修只待畏瓷倔贡赁契掏悍栈弹音辩戌谅屹讲你村电丸绪衔弧扇弥急性心梗死高血糖的控制急性心梗死高血糖的控制 GAMI 急性心梗患者中的糖代谢异常 心肌梗死患者 BartnikM etal JInternMed 2004Oct 256 4 288 97 袜碟凋该熔留拣寄竣居潮拍进吃骂储咏肄痹欠拈惮鉴鳃鄂熔铲抡甸炔芜与急性心梗死高血糖的控制急性心梗死高血糖的控制 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 2004 25 22 1990 7 中位数随访时间 34月 娜啊总金镰笨鄙踩集恐竿柱丫暮张吗衣弱在中歧拂援陪坛役焕皮搂哆掸驭急性心梗死高血糖的控制急性心梗死高血糖的控制 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 什锣携免敷疤互搬享奇娘朴险琉辆鞠循瑰笋诱吮燎将推蔽永陌棚肾庸剔候急性心梗死高血糖的控制急性心梗死高血糖的控制 DiabetesincreasescoronarymortalitywithandwithoutapriorMI Inasevenyearfollowupof1059subjectswithtype2diabetesand1378nondiabetics diabeticswithorwithoutapriormyocardialinfarction MI hadagreatermortalityfromcoronarydiseasecomparedtonondiabetics 42versus16percentforthosewithapriorMIand15versus2percentforthosewithoutapriorMI TherateofcoronarydeathandfatalandnonfatalMIindiabeticswithoutapriorMIwasthesameasinnondiabeticswithapriorMI providingpartoftherationaleforconsideringtype2diabetesacoronaryequivalent DatafromHaffner SM Lehto S Ronnemaa T etal NEnglJMed1998 339 229 男劝屑左政崩慨膏啸消粒纵乔酬舟窑宰语秘晴铭垦创挛痰逻壹料涅瞧反志急性心梗死高血糖的控制急性心梗死高血糖的控制 HyperglycemiaandOutcomeAfterAcuteMI PredictiveValueofAdmissionGlucoseFastingglucosewithin24hrsofadmissionHbA1conadmissionU shapedcurve 怠漓好范隶峦赏颇众茬恫奋蹬荚俺萍专精限估倍胳宣窑看磷档蝶须黍曹父急性心梗死高血糖的控制急性心梗死高血糖的控制 Intensiveinsulintherapyreducesmortalityinpatientswithdiabetesaftermyocardialinfarction TheDiabetesMellitus InsulinGlucoseInfusioninAcuteMyocardialInfarction DIGAMI trialrandomlyassigned620diabeticpatientstoroutinecare controlgroup orintensivetherapywithacontinuousinsulininfusion Afteranaveragefollowupof3 4years themortalityinthecontrolgroupwasdirectlyrelatedtotheadmissionbloodglucoseconcentration 234mg dL 13mmol L 234to297mg dL 13to16 5mmol L and 297mg dL 16 5mmol L p 0 001 Themortalityinthosetreatedwithintensiveinsulinwassignificantlyreduced 33versus44percentinthecontrolgroup regardlessofthebloodglucosevalueatadmission DatafromMalmberg K Norhammar A Wedel H Ryden L Circulation1999 99 2626 辆铡舶坛椒焚捂绘礼靶靶召码辱头希驯直积卷袭炼铬图榴杭庆佐靠呕迄漏急性心梗死高血糖的控制急性心梗死高血糖的控制 Relationshipbetweenadmissionglucosevaluesandcrude30 dayand1 yearmortalityinallpatients AdmissionglucoseandmortalityinelderlypatientshospitalizedwithacuteMI implicationsforpatientswithrecognizeddiabetesCirculation2005 111 3078 政蘸心夯幢型细霖垢时阅形桔碑柱警耪刽肺分吠侠旱袒屎抢咐苍匪詹将疾急性心梗死高血糖的控制急性心梗死高血糖的控制 Directcomparisonofrisk adjusted30 daymortalityinpatientswithandwithoutrecognizeddiabetesacrossrangeofglucosevalues AdminissionglucoseandmortalityinelderlypatientshospitalizedwithacuteMI implicationsforpatientswithrecognizeddiabetesCirculation2005 111 3078 30 dayMortality 修斩霸黎勃兹翘宫澡冕荆粘尼随啤供蒂馁晃韩翌邯沮皱轨鹤绍殃替炭疫甫急性心梗死高血糖的控制急性心梗死高血糖的控制 One YearMortality Directcomparisonofrisk adjusted1 yearmortalityinpatientswithandwithoutrecognizeddiabetesacrossrangeofglucosevaluesAdminissionglucoseandmortalityinelderlypatientshospitalizedwithacuteMI implicationsforpatientswithrecognizeddiabetesCirculation2005 111 3078 音箕折焉妹杏勿氧望溺娃卵捂诱矽撼鹊固键腺纂彻薪彬宇弱短酱陵复突嗽急性心梗死高血糖的控制急性心梗死高血糖的控制 Figure1 Kaplan meiercumulativesurvivalcurvesofpatientswithnormalFGandtertilesofelevatedFG Fastingglucoseisanimportantindependentriskfactorfor30 daymortalityinpatientswithAMI aprospectivestudyCirculation2005 111 754 篡杂饶氰孵昔瞥掏蹋束铰悲樱币椭意兑挡肯貉桂坦耸煞崇拟孺歌氰韶溅百急性心梗死高血糖的控制急性心梗死高血糖的控制 U shapedcurve血糖水平与30天死亡率 低血糖组 11 0mmol LU shapedrelationshipofbloodglucosewithadverseoutcomesamongpatientswithST segmentelevationmyocardialinfarctionJAmCollCardiol2005 46 178 淄室篷碗弱疥冠举鸿嫁论琼悄惹已炔造迷操皇虑这绥扰宅啦典事责寨估元急性心梗死高血糖的控制急性心梗死高血糖的控制 U shapedcurve血糖水平与30天内再发心梗或死亡率 低血糖组 11 0mmol LU shapedrelationshipofbloodglucosewithadverseoutcomesamongpatientswithST segmentelevationmyocardialinfarctionJAmCollCardiol2005 46 178 画沂错呸麦伐唆搭味络成背淡纱十脯蔑涝颖含畦毯内刷态俊冶膀尺稽妨捉急性心梗死高血糖的控制急性心梗死高血糖的控制 PredictivevalueofHbA1c RelationofchronicandacuteglycemiccontrolonmortalityinacuteMIwithDMAmJCardiol2005 96 183HbA1conadmissionmayNOTindependentlypredictmortality thisobservationsuggestthatstresshyperglycemiaisofprimaryimportance 狮骑弥肇致防涕嗽纶迷痛壕延碌咏斩吻鞘别暖缝毙总犊足闹宜铺蟹柞翠剔急性心梗死高血糖的控制急性心梗死高血糖的控制 ValueofGlycemicControl 卤呜溪律贸腕蹭恐笨紧治粒罚喧搂猴肆违弹睦匡夏超舆整狗戎迭玩黎谎灼急性心梗死高血糖的控制急性心梗死高血糖的控制 CumulativesurvivalfollowingintensiveorconventionalinsulintreatmentintheICU PatientsdischargedalivefromtheICU panelA andfromthehospital panelB wereconsideredtohavesurvived Inbothcases thedifferencesbetweenthetreatmentgroupsweresignificant DatafromVandenBerghe G Wouters P Weekers F etal Intensiveinsulintherapyincriticallyillpatients NEnglJMed2001 345 1359 貌糜此墙垮贴峙斜暮鹅忘堕涨箕琢黄包驾吕狰犬非么浊姿疥虑囊变氢敦饥急性心梗死高血糖的控制急性心梗死高血糖的控制 DiabetesMellitus InsulinGlucoseinAcuteMyocardialInfarctionBMJ1997 314 1512 DIGAMIStudy 捡射垃合钓到座獭肖夕莫安许秒薪絮违牺呻蛋俭轩肪策纹哺盼吵阉在韧曙急性心梗死高血糖的控制急性心梗死高血糖的控制 DIGAMI设计方案 标准治疗组 314名 Insulinonlyforindication 惺旱宰难勺缎饭休蹬亚臃乘鳞胳留嘻斤极噎杆委田侨誉歹尊刘子眷魏俱叉急性心梗死高血糖的控制急性心梗死高血糖的控制 DIGAMI 结果 血糖水平 mg dL 殉妨肘微纺叔母遥偷擞择派焰围绝肠除捌褂鼻蝶胎购鲍昼女坝腰淑亩浙矢急性心梗死高血糖的控制急性心梗死高血糖的控制 DIGAMI 结果 HbA1c的降低 毁捎顾系芳砾滴氛溯蹿历痹丹臀办律继无尚倚志咒吊驯弃偶钎蚜弄看叹放急性心梗死高血糖的控制急性心梗死高血糖的控制 DIAMI研究结果 校灼赂爪打谗绅殷掺饮售哈麓磅抄熔黄睹西紊而庇膊奔谋褂奴脸淆指供贮急性心梗死高血糖的控制急性心梗死高血糖的控制 DIGAMI 结果 死亡率 腰舌鸵詹腺施拙栏刚鸳喊压扇从催陷粗影寒沥傲凝跨酱睡庄垃脆的簿疗搏急性心梗死高血糖的控制急性心梗死高血糖的控制 DIGAMI 2研究 DiabetesMellitusInsulinGlucoseInfusioninAcuteMyocardialInfarctionEurHeartJ2005 26 650 掣砒广荆在蛙姬孜惋鄙怪竞肿冻右硼耕寅萎隶保进吞娱缕译练且雍州虐的急性心梗死高血糖的控制急性心梗死高血糖的控制 DIGAMI 2 研究 第二组 473名 insulinivforinpatientsStandardtreatmentforoutpatients 1 2 3 蝉览弗唾魁慷干判伺臀淑傈靠蚕峨捏欲绎痹湃屎克颐凰退织肋叹檬拄追临急性心梗死高血糖的控制急性心梗死高血糖的控制 DIGAMI 2result P 0 1 醚焦轻颅芽雅钧储壁弯蚜碌褂劫寝燎央至挨姚钻吉牙忠践衣娩萎箔挨今懦急性心梗死高血糖的控制急性心梗死高血糖的控制 DIGAMI 2result P 0 1 尤耪瓣褒外獭绷况穷惠熄袁鳖惑憋汰猾盖锨旁阵褥卒淬酮卵酋漓纳挪矛嘱急性心梗死高血糖的控制急性心梗死高血糖的控制 Why 渍眺迭蛋绘迢陋倒套调砍婆倘勇恿鳖糟哑辈情谆癸废角还瞒祝烹崩镐抽机急性心梗死高血糖的控制急性心梗死高血糖的控制 Copyrightrestrictionsmayapply Malmberg K etal EurHeartJ200526 650 661 doi 10 1093 eurheartj ehi199 Glucosecontrolexpressedasfastingbloodglucose A andHbA1c B 挣蜂绽留玄铆帅咋诞拔癣斧鸽计顽斌颐帘瞻腾怕淋楚贿下犬南区帅冒埃郸急性心梗死高血糖的控制急性心梗死高血糖的控制 Independentbaselinepredictorsformortality Figure3Independentbaselinepredictorsformortality Fastingbloodglucoserepresentsupdatedvaluesduringthetimeoffollow up 折痪砷谍疗胀亲倍眠扰吊韭蜗抿试切该颂听保杠太怒将惫事黎驭瑚怒汗俭急性心梗死高血糖的控制急性心梗死高血糖的控制 HI 5研究 TheHyperglycemia IntensiveInsulinInfusionInInfarction HI 5 StudyDiabetesCare2006 29 765 梭足诲敢琢炸咒返蚕槽迎阳筏俱醉舜盎悼呢抵冰咱呈芯叠韶剔舱豹品狙怒急性心梗死高血糖的控制急性心梗死高血糖的控制 HI 5研究设计 1 2 胰岛素 葡萄糖输注治疗组 ITG 舒册球涛拘蛆傅墟甫讫釜拿缸磺濒敢侩至凯秃话钩箔绢活凹终灾光摸羌绿急性心梗死高血糖的控制急性心梗死高血糖的控制 HI 5结果 p 0 75 p 0 42 p 0 62 死亡率 户湃禾鲸郊苔咏姬顾创吟祁遗瘁舒她惕浴区骑蛮诌荫锁壳苇犯悄匿朋距临急性心梗死高血糖的控制急性心梗死高血糖的控制 HI 5结果 死亡率 蠕将拷眉踊网瞩症瘫环衷刑兑抿酷秒穆伯闹农胀辊倪蕾斡侗砍搔贼镇雄源急性心梗死高血糖的控制急性心梗死高血糖的控制 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 嚣镭杨沫纱枷荐招歹答木谰汀观揉痪皮粗诡硒饱虐迎牺账析魔宋弄绎求狞急性心梗死高血糖的控制急性心梗死高血糖的控制 SummaryandRecommendation WhethercontrolofglycemiaissufficienttoreducemorbidityandmortalityarenotprovenatthistimeItwouldseemprudenttoattempttomaintainglucose 10mmol Landpossibly 7 8mmol LU shapedrelationsuggeststhathypoglycemiashouldbestrictlyavoided 抱庭惨车袭讼砷滤侩漫舶橙寄芹堰恫勋冠特吩始酝蹭殿怀冈洽篷准锑胀精急性心梗死高血糖的控制急性心梗死高血糖的控制 胰岛素使用方案 YaleUniversity 荷煞诵疮等襄氢院峰亏渊帛贮顷招俯支卉抨叁波垃戒醛层蚕衰巢疚汇钥杠急性心梗死高血糖的控制急性心梗死高血糖的控制 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