急性心肌梗死高血糖的控制

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 2004 25 1880 1890 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 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 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 NEnglJMed1998 339 229 HyperglycemiaandOutcomeAfterAcuteMI PredictiveValueofAdmissionGlucoseFastingglucosewithin24hrsofadmissionHbA1conadmissionU shapedcurve 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 Relationshipbetweenadmissionglucosevaluesandcrude30 dayand1 yearmortalityinallpatients AdmissionglucoseandmortalityinelderlypatientshospitalizedwithacuteMI implicationsforpatientswithrecognizeddiabetesCirculation2005 111 3078 Directcomparisonofrisk adjusted30 daymortalityinpatientswithandwithoutrecognizeddiabetesacrossrangeofglucosevalues AdminissionglucoseandmortalityinelderlypatientshospitalizedwithacuteMI implicationsforpatientswithrecognizeddiabetesCirculation2005 111 3078 30 dayMortality One YearMortality Directcomparisonofrisk adjusted1 yearmortalityinpatientswithandwithoutrecognizeddiabetesacrossrangeofglucosevaluesAdminissionglucoseandmortalityinelderlypatientshospitalizedwithacuteMI implicationsforpatientswithrecognizeddiabetesCirculation2005 111 3078 Figure1 Kaplan meiercumulativesurvivalcurvesofpatientswithnormalFGandtertilesofelevatedFG Fastingglucoseisanimportantindependentriskfactorfor30 daymortalityinpatientswithAMI aprospectivestudyCirculation2005 111 754 U shapedcurve血糖水平与30天死亡率 低血糖组 11 0mmol LU shapedrelationshipofbloodglucosewithadverseoutcomesamongpatientswithST segmentelevationmyocardialinfarctionJAmCollCardiol2005 46 178 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 PredictivevalueofHbA1c RelationofchronicandacuteglycemiccontrolonmortalityinacuteMIwithDMAmJCardiol2005 96 183HbA1conadmissionmayNOTindependentlypredictmortality thisobservationsuggestthatstresshyperglycemiaisofprimaryimportance ValueofGlycemicControl CumulativesurvivalfollowingintensiveorconventionalinsulintreatmentintheICU PatientsdischargedalivefromtheICU panelA andfromthehospital panelB wereconsideredtohavesurvived Inbothcases thedifferencesbetweenthetreatmentgroupsweresignificant DatafromVandenBerghe G Wouters P Weekers F etal Intensiveinsulintherapyincriticallyillpatients NEnglJMed2001 345 1359 DiabetesMellitus InsulinGlucoseinAcuteMyocardialInfarctionBMJ1997 314 1512 DIGAMIStudy DIGAMI设计方案 标准治疗组 314名 Insulinonlyforindication DIGAMI 结果 血糖水平 mg dL DIGAMI 结果 HbA1c的降低 DIAMI研究结果 DIGAMI 结果 死亡率 DIGAMI 2研究 DiabetesMellitusInsulinGlucoseInfusioninAcuteMyocardialInfarctionEurHeartJ2005 26 650 DIGAMI 2 研究 第二组 473名 insulinivforinpatientsStandardtreatmentforoutpatients 1 2 3 DIGAMI 2result P 0 1 DIGAMI 2result P 0 1 Why Copyrightrestrictionsmayapply Malmberg K etal EurHeartJ200526 650 661 doi 10 1093 eurheartj ehi199 Glucosecontrolexpressedasfastingbloodglucose A andHbA1c B Independentbaselinepredictorsformortality Figure3Independentbaselinepredictorsformortality Fastingbloodglucoserepresentsupdatedvaluesduringthetimeoffollow up HI 5研究 TheHyperglycemia IntensiveInsulinInfusionInInfarction HI 5 StudyDiabetesCare2006 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 WhethercontrolofglycemiaissufficienttoreducemorbidityandmortalityarenotprovenatthistimeItwouldseemprudenttoattempttomaintainglucose 10mmol Landpossibly 7 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