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1、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,The Euro Heart Survey on diabetes and the heart，European Heart Journal (2004) 25, 18801890,GAMI:急性心梗患者中的糖代谢异常,心肌梗死患者,Bartnik M, et al. J Intern Med. 2004 Oct;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,Bartnik M, et al. Eur Heart J. 2
2、004;25(22):1990-7.,中位数随访时间:34月,Diabetics 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 had diabetes. After a two year follow-u
3、p, 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; 102:1014.,Diabetes increases coronary morta
4、lity 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 versus 16 percent for those with a prior MI
5、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 coronary equivalent. Data from Haffner, SM, Le
6、hto, S, Ronnemaa, T, et al, N Engl J Med 1998; 339:229.,Hyperglycemia and Outcome After Acute MI,Predictive Value of Admission Glucose Fasting glucose within 24hrs of admission HbA1c on admission U-shaped curve,Intensive insulin therapy reduces mortality in patients with diabetes after myocardial in
7、farction,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 years, the mortality in the control
8、 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 percent in the control group) regard
9、less of the blood glucose value at admission. Data from Malmberg, K, Norhammar, A, Wedel, H, Ryden, L, Circulation 1999; 99:2626.,Relationship between admission glucose values and crude 30-day and 1-year mortality in all patients,Admission glucose and mortality in elderly patients hospitalized with
10、acute MI :implications for patients with recognized diabetes Circulation 2005;111;3078,Direct 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 patients hospitalized with acute MI
11、 :implications for patients with recognized diabetes Circulation 2005;111;3078,30-day Mortality,One-Year Mortality,Direct comparison of risk-adjusted 1-year mortality in patients with and without recognized diabetes across range of glucose values Adminission glucose and mortality in elderly patients
12、 hospitalized with acute MI :implications for patients with recognized diabetes Circulation 2005;111;3078,Figure1:Kaplan-meier cumulative survival curves of patients with normal FG and tertiles of elevated FG,Fasting glucose is an important independent risk factor for 30-day mortality in patients wi
13、th AMI :a prospective study Circulation 2005;111:754,U-shaped curve 血糖水平与30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;46:178,U-shaped curve 血糖水平与30天内再发心梗或死亡率,低血糖组：11.0mmol/L U
14、-shaped relationship of blood glucose with adverse outcomes among patients with ST-segment elevation myocardial infarction J Am Coll Cardiol 2005;46:178,Predictive value of HbA1c,Relation of chronic and acute glycemic control on mortality in acute MI with DM Am J Cardiol 2005;96:183 HbA1c on admissi
15、on may NOT independently predict mortality ,this observation suggest that stress hyperglycemia is of primary importance,Value of Glycemic Control,Cumulative survival following intensive or conventional insulin treatment in the ICU,Patients discharged alive from the ICU (panel A) and from the hospita
16、l (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 Engl J Med 2001; 345:1359.,Diabetes Mellitus, Insulin Glucos
17、e in Acute Myocardial Infarction BMJ1997;314:1512,DIGAMI Study,DIGAMI 设计方案,标准治疗组（314名） Insulin only for indication,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,DIGAMI2 研究,Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction Eur Heart J 2005；26：650,DI
18、GAMI-2:研究,第二组（473名） insulin iv for inpatients Standard treatment for outpatients,1,2,3,DIGAMI2 result,P 0.1,DIGAMI2 result,P 0.1,Why?,Copyright restrictions may apply.,Malmberg, K. et al. Eur Heart J 2005 26:650-661; doi:10.1093/eurheartj/ehi199,Glucose control expressed as fasting blood glucose (A)
19、 and HbA1c (B),Independent baseline predictors for mortality,Figure 3 Independent baseline predictors for mortality. Fasting blood glucose represents updated values during the time of follow-up,HI-5 研究,The Hyperglycemia: Intensive Insulin Infusion In Infarction (HI-5) Study Diabetes Care 2006;29:765
20、,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。,Summary and Recommendation,Whether control of glycemia is sufficient to reduce morbidity and mortality are not proven at this time It would seem prudent to attempt to
21、 maintain glucose10mmol/L and possibly 7.8mmol/L U-shaped relation suggests that hypoglycemia should be strictly avoided,胰岛素使用方案,Yale University,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预期不同，或者发生任何指南没有
22、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。,初始胰岛素使用,血糖监测,调整胰岛素输注的速度,调整胰岛素输注的速度,调整胰岛素输注的速度,*注释：停止胰岛素输注，每1530分钟复测一次血糖，当血糖大于或等于90 mg/dL时，按最近胰岛素输注速度的75重新输注胰岛素。,调整胰岛素输注的速度,*注释：根据具体的临床情况，胰岛素输注速度一般为2-10 U/hr。很少超过20 U/hr，如果确实需要这么大量的胰岛素，应该通知主诊医生，寻找其他可能原因，包括技术故障，例如胰岛素输注液配置错误等。,第三步 胰岛素输注速度的改变，即上述表格所示“是根据目前胰岛素输注速度确定的，具体如下表：,THANK YOU !,