糖尿病并发急性冠脉综合征的治疗

糖尿病合并急性冠脉综合征的治疗,谢 红,文献阅读报告,报告内容,文献来源,文献内容简介,文献分析与评论,结论与启示,4,1,2,3,一、文献来源,2007冠心病患者合并高血糖诊治的中国专家共识,中国医师协会心血管内科医师分 会/中国医师协会循证医学专业委员会.夏城东,殷惠军,陈可冀.糖尿病防治的策略转变从关注糖化血红蛋白到着眼心血管事件J.医学与哲学(临床决策论坛版),2009,30（4）,4-7. Frederick Feit, Steven V. Manoukian, Ramin Ebrahimi,et.Safety and Efficacy of Bivalirudin Monotherapy in Patients With Diabetes Mellitus and Acute Coronary Syndromes. Journal of the American College of Cardiology, 2008,51（17）,1645-1652.Giovanni Paolo TalaricoM, Marta BrancatiM, Francesco Burzotta, et. Glycoprotein IIB/IIIA inhibitor to reduce postpercutaneous coronary intervention myonecrosis and improve coronary flow in diabetics: the OPTIMIZE-IT pilot randomized study.Journal of Cardiovascular Medicine, 2009,10(3),245-262.,文献1 糖尿病是冠心病的等危症,糖尿病患者患心血管疾病的危险是无糖尿病者的24倍。无心肌梗死病史的糖尿病患者在未来810年发生心肌梗死的危险高达20%,约等同于已患心肌梗死者再发心肌梗死的危险。而曾发生心肌梗死的糖尿病患者未来再发心肌梗死的危险超过40%。,2007冠心病患者合并高血糖诊治的中国专家共识,中国医师协会心血管内科医师分会/中国医师协会循证医学专业委员会.,文献1 冠心病高血糖处理原则,控制目标：接近6.1mmol/l，10mmol/l，静脉应用胰岛素控制血糖，循序渐进，剂量个体化和血糖监测，避免低血糖发生,稳定型冠心病患者,急性冠脉综合征患者,控制目标：FPG 5.0-7.2mmol/l ， PPG10mmol/l，必要时应用胰岛素治疗,2007冠心病患者合并高血糖诊治的中国专家共识,中国医师协会心血管内科医师分会/中国医师协会循证医学专业委员会.,文献2 以血糖为中心转向以防治心血管事件为中心的多危险因素综合防治,UKPDS有关2型糖尿病冠心病危险因素的分析显示：T2DM患者冠心病危险因素按重要性依次为LDL-Ch、HDL-Ch、SBP、HbA1c与吸烟。DCCT观察发现T1DM HbA1c较常规治疗组明显下降，微血管病变和神经病变终点的风险显著降低，大血管与心血管事件的风险降低并无计学意义。2007年欧洲心脏病学会和欧洲糖尿病研究协会制定诊疗指南，并指出多种危险因素干预更有利于糖尿病和心血管疾病的治疗，并提出了明确的糖尿病合并心血管疾病患者的干预目标。Steno-2研究显示：全面控制血压、血脂、血糖等多种危险因素，可显著改善合并微量蛋白尿T2DM患者的预后，使死亡危险显著降低57%，任一心血管事件危险显著降低59%。,夏城东,殷惠军,陈可冀.糖尿病防治的策略转变从关注糖化血红蛋白到着眼心血管事件J.医学与哲学（临床决策论坛版）,2009,30（4）,4-7.,文献2 糖尿病血糖控制 应早期、长程、持续、稳定,2008年欧洲心脏病学年会报道Monteiro等对1053例急性冠脉综合征患者研究发现，在糖尿病和非糖尿病患者中血糖变异幅度高者，ST段抬高心肌梗死发生率也越高，并且血糖变异幅度与坏死和炎症因子标志物、左室射血分数、肌酐清除率相关。VADT项目Svensson等对713例糖尿病合并急性冠脉事件患者调查发现，入院时的高血糖与住院期间发生的低血糖均与2年后全因死亡风险增加独立相关，说明避免急性冠脉事件中的低血糖和高血糖同等重要。DCCT/EDIC、UKPDS研究发现早期强化降糖治疗对糖尿病心血管并发症具有长期的后续效应。,夏城东,殷惠军,陈可冀.糖尿病防治的策略转变从关注糖化血红蛋白到着眼心血管事件J.医学与哲学（临床决策论坛版）,2009,30（4）,4-7.,文献3糖蛋白IIB/IIIA抑制剂减少糖尿病患者经皮冠脉干预治疗(PCIs)肌坏死和改善冠脉血流,文献3糖蛋白IIB/IIIA抑制剂减少糖尿病患者经皮冠脉干预治疗(PCIs)肌坏死和改善冠脉血流,Methods randomized consecutive stable diabetic patients, undergoing elective PCI, to tirofiban or placebo groups; High-dose bolus (25mg/kg per 3 min) of tirofiban administered before PCI followed by 8 h continuous infusion (0.15mg/kg per min). Postprocedural myonecrosis was assessed prospectively by measurement of cardiac troponin T (cTnT) at 6 and 24 h after PCI. The primary endpoints were post-PCI coronary flow estimated by corrected thrombolysis in myocardial infarction frame count and post- PCI myocardial infarction. Platelet aggregation was measured by platelet function analyser-100 values.,Giovanni Paolo TalaricoM,et.Journal of Cardiovascular Medicine, 2009,10（3）, 245-262.,Giovanni Paolo TalaricoM,et.Journal of Cardiovascular Medicine, 2009,10（3）, 245-262.,文献3 结果（一）,文献3 结果二,文献3 结果三,文献3 结果四,文献3 结论,Conclusions the administration pre-PCI of HBD tirofiban, in stable diabetic patients undergoing elective PCI, was associated with a marked reduction of platelet aggregation；not associated with a significant improvement in the risk of bleeding (with the prevalent radial approach)； which did not translate to a lower incidence of post-PCI myocardial necrosis nor to better myocardial perfusion as compared with placebo.,文献四 比伐卢定单药治疗在糖尿病和急性冠脉综合征患者的安全性和有效性,MethodsWe evaluated the impact of diabetes on 30-day net adverse clinical outcomes (composite ischemia death, myocardial infarction, or unplanned ischemic revascularization or major bleeding), overall and by antithrombotic strategy.,Frederick Feit, Steven V. Manoukian, Ramin Ebrahimi,et.Safety and Efficacy of Bivalirudin Monotherapy in Patients With Diabetes Mellitus and Acute Coronary Syndromes. Journal of the American College of Cardiology, 2008,51（17）,1645-1652.,Groups:Diabetic patients, Nondiabetic patientsSubgroups:Heparin plus GPI, Bivalliudin plus GPI, Bivallirudin monotherapy,文献4 结果一,文献4 结果二,ConclusionsDiabetic patients with ACS managed invasively have higher rates of composite ischemia and major bleeding.Compared with treatment with heparin plus GPI, bivalirudin monotherapy provides similar protection from ischemic events with less major bleeding, resulting in a significant reduction in net adv