胰岛素抵抗、糖尿病与冠心病（英文）课件

1、Epidemiology of Insulin Resistance, Diabetes Mellitus, and Coronary Heart DiseaseSteven Haffner, MDAdapted from World Health Organization. Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications. Geneva: World Health Organization:1999:52.Criteria for the Diagnosis of Diab

2、etes Mellitus and HyperglycemiaPlasma Glucose Concentration7.0 (126) 6.1 (110) to 7.0 (11.1 (200)7.8 (140) to11.1 (20 years) by Year and Region20002025Hospitalization Costs for Chronic Complications of Diabetes in the USAmerican Diabetes Association. Economic Consequences of Diabetes Mellitusin the

3、US in 1997. Alexandria, VA: American Diabetes Association, 1998:1-14.Total costs 12 billion US $CVD accounts for 64% of total costsOthersOphthalmic diseaseCardiovasculardiseaseRenal diseaseNeurologic diseasePeripheral vascular diseaseAnnual CHD Deaths per 1000 PersonsKannel WB, McGee DL. JAMA 1979;2

4、41:2035-2038.Framingham Study: DM and CHD Mortality20-Year Follow-up178174MenWomenDMNon-DMIschemicheartdisease% of DeathsGeiss LS et al. In: Diabetes in America. 2nd ed. 1995; chap 11.Mortality in People with DiabetesCauses of DeathOtherheartdiseaseDiabetesCancerStrokeInfectionOtherMortality per 100

5、0 person-years*Age-adjustedAdapted from Gu K et al. Diabetes Care 1998;21:1138-1145.Mortality Due to Heart Disease in Men and Women with or without Diabetes (US)29.919.2MenWomenDiabetesNo DiabetesAll heart diseaseIschemic heart diseaseMenWomen11.56.323.07.111.03.6WOMENMENCardiovascular Mortality in

6、People with Diabetes% of Deaths (Crude Rate)Adapted from Miettinen H et al. Diabetes Care. 1998;21:69-75.DiabetesNo Diabetes28.622.110.911.9DiabetesNo Diabetes15.49.622.79.09.14.211.12.828 d 1 yHospitalization 28 dOut of HospitalInfluence of Multiple Risk Factors* on CVD Death Rates in Diabetic and

7、Nondiabetic Men: MRFIT ScreeneesNoneOne onlyAge-adjusted CVD death rate per 10,000 person-years*Serum cholesterol 200 mg/dl, smoking, SBP 120 mmHgStamler J et al. Diabetes Care 1993;16:434-444All threeNo diabetesDiabetesTwo onlyPutative Mechanism for Increased Atherosclerosis in Type 2 DiabetesBLACK

8、 BOXDyslipidemiaHypertensionHyperinsulinemia/insulin resistanceHemostatic abnormalitiesHyperglycemiaAGE proteinsOxidative stressAGE = advanced glycation end productsAdapted from Bierman EL. Arterioscler Thromb 1992;12:647-656.Incidence Rates of MI and Microvascular Endpoints by Mean Systolic Blood P

9、ressure: UKPDS110120130140150160170Incidence per 1000 Person Years (%)Adler AI et al. BMJ 2000;321:412-419.Updated Mean Systolic Blood Pressure (mmHg)Adjusted for age, sex, and ethnic groupMyocardial InfarctionMicrovascular EndpointsIncidence Rates of MI and Microvascular Endpoints by Mean Hemoglobi

10、n A1c: UKPDS567891011Incidence per 1000 Person Years (%)Stratton IM et al. BMJ 2000;321:405-412.Updated Mean Hemoglobin A1c Concentration (%)Adjusted for age, sex, and ethnic groupMyocardial InfarctionMicrovascular EndpointsPlasma Insulin and Triglycerides Predict Ischemic Heart Disease: Quebec Card

11、iovascular StudyDespres JP et al. N Engl J Med 1996;334:952-957.Odds Ratio15F-Insulin (U/ml)4.6p=0.005150 mg/dl150 mg/dlTriglycerides1.01.55.3p=0.001P0.0016.75.4P=0.002Plasma Insulin and Apolipoprotein B Predict Ischemic Heart Disease: Quebec Cardiovascular StudyDespres JP et al. N Engl J Med 1996;3

12、34:952-957.Odds Ratio15F-Insulin (U/ml)3.0p=0.04119 mg/dl119 mg/dlApolipoprotein B1.01.53.2p0.00111.09.7P0.001p=0.04Baseline Anthropometric Variables and Cardiovascular Risk Factors in Subjects with Normal Glucose Tolerance at Baseline According to Conversion Status at 8-Year Follow-up: San Antonio

13、Heart StudyBMI (kg/m2)Centrality*TG (mmol)HDLC (mmol)SBP (mmHg)Fasting glucose (mmol)Fasting insulin (pmol)Haffner SM et al. JAMA 1990;263:2893-2898.28.2 + 1.11.38 + 0.091.83 + 0.121.14 + 0.07116.8 + 3.05.28 + 0.1157 + 2727.2 + 0.21.16 + 0.21.26 + 0.101.28 + 0.02108.8 + 0.85.00 + 0.0281 + 5.472.472.

14、006.045.004.032.006Conversion Status at Follow-upDiabetes (n=18)Normal (n=490)P* Ratio of subscapular to triceps skinfolds“Ticking Clock” HypothesisWHO. Diabetologia 1985;28:615-640; Haffner SM et al. JAMA 1990;263:2893-2898.ForMicrovascular complicationsMacrovascular complicationsThe “clock starts

15、ticking”At onset of hyperglycemiaBefore the diagnosis of hyperglycemiaHemoglobin A1Fasting GlucoseThe 7-Year Age-Adjusted Incidence of CHD Mortality and All CHD Events: East-West StudyLehto S et al. Diabetes 1997;46:1354-1359.403020100% IncidenceP-glucose (mmol/L)13.4403020100% IncidenceCHD Mortalit

16、yAll CHD EventsCHD MortalityAll CHD EventsHbA1 (%)10.7Stepwise Selection of Risk Factors* in 2693 White Patients with Type 2 Diabetes with Dependent Variable as Time to First Event: UKPDS VariableLow-Density Lipoprotein CholesterolHigh-Density Lipoprotein CholesterolHemoglobin A1cSystolic Blood Pres

17、sureSmokingP Value0.0001 0.0001 0.0022 0.00650.056Coronary Artery Disease (n=280)Position in ModelFirstSecondThirdFourthFifth*Adjusted for age and sex.Turner RC et al. BMJ 1998;316:823-828.Criteria for Accepting Cardiovascular Risk Factor Management as Similar in Diabetic and CHD SubjectsThe risk of

18、 vascular disease is similar in diabetic subjects without pre-existing vascular disease as in nondiabetic subjects with vascular diseaseGlycemia alone will not completely eliminate the excess of CHD risk in diabetic subjectsLipid interventions to reduce CHD can be equally effective in diabetic and n

19、ondiabetic subjectsIncidence of Fatal or Nonfatal MI During a 7-Year Follow-up in Relation to History of MI in Nondiabetic vs Diabetic Subjects: East-West StudyIncidence During Follow-up (%)(n=69)Nondiabetics with prior MINondiabetics with no prior MIDiabetics with prior MIDiabetics with no prior MI

20、18.8Haffner SM et al. N Engl J Med 1998;339:229-234.(n=1304)(n=169)(n=890)3.00.57.83.23.545.020.2Events per100 person-yr:P0.001p0.001Incidence of Fatal or Nonfatal Stroke During a 7-Year Follow-up in Relation to History of MI in Nondiabetic vs Diabetic Subjects: East-West StudyIncidence During Follo