急性心肌梗死高血糖的控制ppt课件

1、急性心肌梗死高血糖的控制肖 海 鹏1;.23欧洲心脏调查结果欧洲心脏调查结果- -分组分组n=2107n=2854The Euro Heart Survey on diabetes and the heart，European Heart Journal (2004) 25, 188018904GAMI:急性心梗患者中的糖代谢异常急性心梗患者中的糖代谢异常心肌梗死患者心肌梗死患者Bartnik M, et al. J Intern Med. 2004 Oct;256(4):288-97. 5GAMI :新诊断高血糖新诊断高血糖是心肌梗死后是心肌梗死后“无心血管事件存活无心血管事件存活”的预测因

2、素的预测因素Bartnik M, et al. Eur Heart J. 2004;25(22):1990-7. 中位数随访时间:34月6Diabetics with a non-ST elevation ACS have a worse outcome than nondiabetics In the OASIS registry of 8013 patients with a non-ST elevation acute coronary syndrome (unstable angina or non Q-wave myocardial infarction), 21 percent h

3、ad diabetes. After a two year follow-up, diabetic patients had a significantly higher combined event rate (cardiovascular death, new myocardial infarction, stroke, new heart failure) than nondiabetics (relative risk 1.56). Data from Malmberg, K, Yusuf, S, Gerstein, HC, et al. Circulation 2000; 102:1

4、014. 7Diabetes increases coronary mortality with and without a prior MI In a seven year follow up of 1059 subjects with type 2 diabetes and 1378 nondiabetics, diabetics with or without a prior myocardial infarction (MI) had a greater mortality from coronary disease compared to nondiabetics (42 versu

5、s 16 percent for those with a prior MI and 15 versus 2 percent for those without a prior MI. The rate of coronary death and fatal and nonfatal MI in diabetics without a prior MI was the same as in nondiabetics with a prior MI, providing part of the rationale for considering type 2 diabetes a coronar

6、y equivalent. Data from Haffner, SM, Lehto, S, Ronnemaa, T, et al, N Engl J Med 1998; 339:229. 8Hyperglycemia and Outcome After Acute MIPredictive Value of Admission GlucoseFasting glucose within 24hrs of admissionHbA1c on admissionU-shaped curve9Intensive insulin therapy reduces mortality in patien

7、ts with diabetes after myocardial infarction The Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI) trial randomly assigned 620 diabetic patients to routine care (control group) or intensive therapy with a continuous insulin infusion. After an average followup of 3.4

8、 years, the mortality in the control group was directly related to the admission blood glucose concentration ( 234 mg/dL 13 mmol/L, 234 to 297 mg/dL 13 to 16.5 mmol/L, and 297 mg/dL 16.5 mmol/L) (p 0.001). The mortality in those treated with intensive insulin was significantly reduced (33 versus 44

9、percent in the control group) regardless of the blood glucose value at admission. Data from Malmberg, K, Norhammar, A, Wedel, H, Ryden, L, Circulation 1999; 99:2626. 10Relationship between admission glucose values andcrude 30-day and 1-year mortality in all patientsAdmission glucose and mortality in

10、 elderly patients hospitalized with acute MI :implications for patients with recognized diabetes Circulation 2005;111;307811Direct comparison of risk-adjusted 30-day mortality in patients with and without recognized diabetes across range of glucose values.Adminission glucose and mortality in elderly

11、 patients hospitalized with acute MI :implications for patients with recognized diabetes Circulation 2005;111;307830-day Mortality12One-Year MortalityDirect comparison of risk-adjusted 1-year mortality in patients with and without recognized diabetes across range of glucose valuesAdminission glucose

12、 and mortality in elderly patients hospitalized with acute MI :implications for patients with recognized diabetes Circulation 2005;111;3078 13Figure1:Kaplan-meier cumulative survival curves of patients with normal FG and tertiles of elevated FGFasting glucose is an important independent risk factor

13、for 30-day mortality in patients with AMI :a prospective study Circulation 2005;111:75414U-shaped curve血糖水平与血糖水平与30天死亡率天死亡率低血糖组：11.0mmol/L U-shaped relationship of blood glucose with adverse outcomes among patients with ST-segment elevation myocardial infarction J Am Coll Cardiol 2005;46:17815U-shap

14、ed curve血糖水平与血糖水平与30天内再发心梗或死亡率天内再发心梗或死亡率低血糖组：11.0mmol/L U-shaped relationship of blood glucose with adverse outcomes among patients with ST-segment elevation myocardial infarction J Am Coll Cardiol 2005;46:178 16Predictive value of HbA1cRelation of chronic and acute glycemic control on mortality in

15、acute MI with DM Am J Cardiol 2005;96:183HbA1c on admission may NOT independentlypredict mortality ,this observation suggest that stress hyperglycemia is of primary importance17Value of Glycemic Control18Cumulative survival following intensive or conventional insulin treatment in the ICU Patients di

16、scharged alive from the ICU (panel A) and from the hospital (panel B) were considered to have survived. In both cases, the differences between the treatment groups were significant. Data from Van den Berghe, G, Wouters, P, Weekers, F, et al. Intensive insulin therapy in critically ill patients. N En

17、gl J Med 2001; 345:1359. 19Diabetes Mellitus, Insulin Glucose in Acute Myocardial Infarction BMJ1997;314:1512 DIGAMI Study20DIGAMI DIGAMI 设计方案设计方案标准治疗组（标准治疗组（314名）名）Insulin only for indication620620名患者名患者AMI and DMAMI and DM强化胰岛素组强化胰岛素组 （306名）名）前前24h insulin+glucose ivThen 4次次insulin s,c21DIGAMI: DI

18、GAMI: 结果结果血糖水平血糖水平（mg/dL ） 22DIGAMIDIGAMI： 结果结果HbA1c 的降的降低（低（%）23DIAMI研究研究 结果结果24DIGAMI: DIGAMI: 结果结果 死亡率死亡率DIGAMIDIGAMI2 2 研究研究Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction Eur Heart J 2005；26：65025;.26DIGAMI-2:DIGAMI-2:研究研究第二组（第二组（473名）名）insulin iv for inpatientsStandar

19、d treatment for outpatients12312531253名患者名患者Type 2 DM Type 2 DM AMIAMI第一组（第一组（474名）名）insulin iv for inpatientsInsulin s,c for outpatients第三组（第三组（306名）名）Both inpatients and outpatients treated according to local practice27DIGAMI2 resultP 0.128DIGAMI2 resultP 0.129Why?30Copyright restrictions may appl

20、y.Malmberg, K. et al. Eur Heart J 2005 26:650-661; doi:10.1093/eurheartj/ehi199Glucose control expressed as fasting blood glucose (A) and HbA1c (B)31Independent baseline predictors for mortalityFigure 3 Independent baseline predictors for mortality.Fasting blood glucose represents updated values dur

21、ing the time of follow-up 32HI-5 HI-5 研究研究 The Hyperglycemia: Intensive Insulin Infusion In Infarction (HI-5) Study Diabetes Care 2006;29:76533HI-5 HI-5 研究设计研究设计12胰岛素胰岛素/葡萄糖输注治疗组葡萄糖输注治疗组(ITG) 240240名患者名患者With DM history,orWith DM history,or PBG140 mg/dL PBG140 mg/dLAMIAMI常规治疗组（常规治疗组（CTG） 34HI-5 HI-5

22、 结果结果p=0.75p=0.42p=0.62死亡率死亡率(%)35HI-5 HI-5 结果结果死亡率死亡率36HI-5 HI-5 研究的意义研究的意义 糖尿病急性心肌梗死患者将血糖控制在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。是必要的。37Summary and RecommendationWhether control of glycemia is sufficient to reduce morbidity and mortality are not proven at this timeIt would seem prudent to atte

23、mpt to maintain glucose10mmol/L and possibly 7.8mmol/LU-shaped relation suggests that hypoglycemia should be strictly avoided胰岛素使用方案胰岛素使用方案Yale University38;.39注注 意意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500 mg/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

24、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密检测电介质情况，尤其是血钾的情况。 401. 胰岛素输注：1U常规人胰岛素/ 1 mL生理盐水通过微泵静脉输入。2. 起始：在开始胰岛素输注前，经静脉输液管推注20 mL胰岛素输注液以饱和输液管上的胰岛素吸附位点。3. 阈值：对于任何重症患者，如果血糖持续大于或等于140 mg/dL，应该静脉输注胰岛素；如果血糖大于120 mg/dL，可以考虑用。 4. 目标血糖水平：90-120 mg/dL5. 首剂和起始胰岛素输注速度：如果初始血糖大于或等于150 mg/dL，则将血糖值除以70，取近似值，即为首

25、剂及起始胰岛素输注速度；如果初始血糖小于150 mg/dL，同样将血糖值除以70取近似值，但不用首剂。举例：1. 初始血糖335 mg/dL，335/70 = 4.78，取近似值5，则首剂为5 U静脉推注，起始胰岛素速度为5 U/hr。2. 起始血糖=148 mg/dL, 148/70 = 2.11,取近似值2，不用首剂，起始胰岛素速度为2 U/hr。 初始胰岛素使用初始胰岛素使用41血糖监测血糖监测 1. 每小时测一次血糖直至血糖稳定，即连续3次测得血糖在目标值范围内。在低血压的患者，毛细血管血糖（指尖血糖）可能不准确，应该通过静脉留置管采血。2. 然后每2小时测一次血糖，一旦血糖稳定122

26、4小时以后，如果满足以下条件，可以每隔34小时测一次血糖。 a. 临床症状没有明显变化并且 b. 营养摄入没有明显改变3. 如下有以下任何一种情况发生，应该考虑短期恢复每小时一次的血糖检测，直至血糖再次稳定： a. 任何胰岛素输注速度的改变，比如血糖超出目标值时调整胰岛素用量。 b. 临床情况有明显改变 c. 开始或终止升压药或激素治疗 d. 开始或终止透析或 CVVH（持续静脉静脉血液透析滤过）治疗 e. 开始或终止营养支持治疗或调整其速度。营养支持包括完全肠外营养、部分肠外营养及鼻饲等。42调整胰岛素输注的速度调整胰岛素输注的速度 如果血糖小于50 mg/dL： 停止胰岛素输注 静脉注射25克50%的葡萄糖，每1015分钟后复测一次血糖。 当血糖大于或等于90 mg/dL时，再观察1小时，然后复测血糖