控制糖尿病患者心血管危险的干预治疗策略.ppt

控制糖尿病患者心血管危险的干预治疗策略 糖尿病与心血管危险影响心血管危险的因素综合控制的理论与实践 countrieswithhighestnumbersofestimatedcasesofdiabetesfor2000and2030 ranking country peoplewithdiabetes millions country peoplewithdiabetes millions 2000 2030 1india31 7india79 42china20 8china42 33u s 17 7u s 30 34indonesia8 4indonesia21 35japan6 8pakistan13 96pakistan5 2brazil11 37russianfederation4 6bangladesh11 18brazil4 6japan8 99italy4 3pinecones7 810bangladesh3 2egypt16 7 total 177million 366millionby2030 type2diabetesandchd7 yearincidenceoffatal nonfatalmi eastweststudy incidenceduringfollow up n 69 nondiabeticswithpriorminondiabeticswithnopriormidiabeticswithpriormidiabeticswithnopriormi 18 8 haffnersmetal nengljmed1998 339 229 234 n 1304 n 169 n 890 3 0 0 5 7 8 3 2 3 5 45 0 20 2 eventsper100person yr p 0 001 p 0 001 type2diabetesandstroke7 yearincidenceoffatal nonfatalstroke eastweststudy incidenceduringfollow up n 69 nondiabeticswithpriorminondiabeticswithnopriormidiabeticswithpriormidiabeticswithnopriormi 7 2 haffnersmetal nengljmed1998 339 229 234 n 1304 n 169 n 890 1 2 0 3 3 4 1 6 1 9 19 5 10 3 eventsper100person yr p 0 01 p 0 001 prevalenceofchdbythemetabolicsyndromeanddiabetesinthenhanespopulationage50 alexandercetal diabetes2003 52 1210 1214 25 20 15 10 5 0 noms nodm 8 7 13 9 7 5 19 2 ms nodm dm noms dm ms ofpopulation 54 2 28 7 2 3 14 8 chdprevalence schillacig jacc 2004 43 1817 1822 代谢综合征与心血管危险 mlandmicrovascularendpoints incidencebymeansystolicbpandhba1cconcentration ml microvascularandpoints ml microvascularandpoints 50 40 30 20 10 0 80 60 40 20 0 adjustedincidenceper1000person yr 110 120 130 140 150 160 170 5 6 7 8 9 10 11 updatedmeansystolicbp mmhg updatedmeanhba1cconcentration adjustedincidenceper1000person yr adleraletal bmj2000 321 412 419 strationimetal bmj2000 321 405 412 mets和dm患者血脂异常特征 游离脂肪酸 tg hdl c vldl c 小而密ldl颗粒 氧化ldl c 餐后高脂血症 male gender adjusted female reducedriskwithsmall denseldl 0 1 relativeriskformyocardialinfarction 1 10 increasedriskwithsmall denseldl small denseldlincreasescardiovascularrisk ukpdsstepwiseselectionofriskfactors inpatientswithtype2diabetes variableldl chdl chemoglobina1csystolicbloodpressuresmoking pvalue 0 00010 00010 00220 00650 056 coronaryarterydisease n 280 positioninmodelfirstsecondthirdfourthfifth adjustedforageandsex turnerrcetal bmj1998 316 823 828 mangagingoverweightintype2diabetics effectiveweightmanagementisthefirststepintreatingtype2diabetes weightloss kg infirst12months leanmejetal diabetmed 1990 7 228 233 weightlossisdifficulttomaintainbydietandexercisealoneintype2diabetes ukpds34 lancet1998 352 354 insulin chlorpropamide gllbenclamide dietalone metformin weightchange kg 7 6 5 4 3 2 1 0 1 0 2 4 6 8 10 yearsfromrandomisation goodglycemiccontrolisnotenough ukpds goodglycemiccontrol microvascularcomplicationssignificantreductions macrovascularcomplicationsnosignificanteffect proactivestudy sept 2005 欧洲糖尿病会议 pioglitazonevsplacebo accordstudyactiontocontrolcardiovascularriskindiabetes prisantlm jclinpharmacol2004 44 4 423 430 hba1c 6 0 vs7 0 7 9 糖尿病患者降压治疗临床试验 shep allhatsyst eur hopecappp hotnordil renaalstop 2 primeinsight lifeukpds majorcardiovascularevents per100patients years inalltreatedhypertensiveandinhypertensivepatientswithdiabetesinrelationtotargetbloodpressuresof90 85 and80mmhg hotstudy resultsinpatientswithdm effectofintensivevsmoderateantihypertensivetreatmentonstrokeincidenceindiabeticnormotensives intensivemoderateachievedbp mmhg 128 75137 81stroke 1 75 4 schrieretal kidneyint2002 61 1086 chdpreventiontrialswithstatinsindiabeticsubjectssubgroupanalyses primarypreventionafcaps texcapssecondarypreventioncare4slipid4s extended chdriskreduction overall drug no lovastatinpravastatinsimvastatinpravastatinsimvastatin 43 25 p 0 05 55 p 0 002 19 42 p 0 001 37 23 32 25 32 239586202782483 chdriskreduction diabetes study adaptedfromdownsjretal jama1998 279 1615 1622 goldbergrbetal circulation1998 98 2513 2519 py r l ketal diabetescare1997 20 614 620 thelong terminterventionwithpravastatininischaemicdisease lipid studygroup nengljmed1998 339 1349 1357 haffnersmetal archinternmed1999 159 2661 2667 cards 主要终点 年 安慰剂组事件数127 立普妥 组事件数83 累积危险 0 5 10 15 0 1 2 3 4 4 75 p 0 001 colhounhm betteridgedj durringtonpn etal lancet 2004 364 685 696 37 trialswithfibratesinpatientswithdiabetes fieldstudyfenofibrateinterventionandeventloweringindiabetes mazzonet amjcardiol2004 93 27c 31c 糖尿病患者心血管危险因素的控制目标 减轻体重 降糖 hba1c 7 0 降压 130 80 调脂 ldl c 1 81mmol l steno 2studymultifactorialinterventionandcardiovasculardiseaseinpatientswithtype2diabetes gradep etal nengljmed2003 348 383 393 steno 2 intensivetherapy nejm2000 342 905 912 basicintervention 脂肪摄入 30 饱和脂肪酸摄入 10 运动30 3 5次 waceiorarb多种维生素aspirin pharmacologyintervention 降糖metformingliclazidemetformin gliclazide降压thiazideaceiorarb ccb blocker降脂statins steno 2 treatmentgoals variableconventionalintensivetherapytherapysbp mmhg 140 130dbp mmhg 85 80hba1c 6 5 6 5tc mg dl 190 175tg mg dl 150 150 steno 2changeinclinicalvariablesattheendofthestudy variableconventionalintensiveptherapytherapysbp mmhg 3 3 14 2 0 001dbp mmhg 8 2 12 20 006carbohydrates 4 8 0 99 3 0 9 0 001 fpg mg dl 18 11 52 8 0 001hba1c 0 2 0 3 0 5 0 2 0 001tc mg dl 3 7 50 4 0 001ldl c mg dl 13 6 47 5 0 001tg mg dl 9 43 41 140 015 steno 2study compositeendpoint gradepetal nengljmed2003 348 383 393