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1、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,Countries With Highest Numbers of Estimated Cases of Diabetes for 2000 and 2030,Ranking,Country,People with diabetes (millions),Country,People with diabetes (millions),2000,2030,1 India 31.7 India 79.4 2 China 20.8 China 42.3 3 U.S. 17.7 U.S. 30.3
2、 4 Indonesia 8.4 Indonesia 21.3 5 Japan 6.8 Pakistan 13.9 6 Pakistan 5.2 Brazil 11.3 7 Russian Federation 4.6 Bangladesh 11.1 8 Brazil 4.6 Japan 8.9 9 Italy 4.3 Pinecones 7.8 10 Bangladesh 3.2 Egypt1 6.7,Total: 177 million,366 MILLION BY 2030,Type 2 diabetes and CHD 7-Year Incidence of Fatal/Nonfata
3、l MI (East West Study),Incidence During Follow-up (%),(n=69),Nondiabetics with prior MI Nondiabetics with no prior MI Diabetics with prior MI Diabetics with no prior MI,18.8,Haffner SM et al. N Engl J Med 1998;339:229-234.,(n=1304),(n=169),(n=890),3.0,0.5,7.8,3.2,3.5,45.0,20.2,Events per 100 person-
4、yr:,P0.001,p0.001,Type 2 diabetes and Stroke 7-Year Incidence of Fatal/Nonfatal Stroke (East West Study),Incidence During Follow-up (%),(n=69),Nondiabetics with prior MI Nondiabetics with no prior MI Diabetics with prior MI Diabetics with no prior MI,7.2,Haffner SM et al. N Engl J Med 1998;339:229-2
5、34.,(n=1304),(n=169),(n=890),1.2,0.3,3.4,1.6,1.9,19.5,10.3,Events per 100 person-yr:,P=0.01,p0.001,Prevalence of CHD by the Metabolic Syndrome and Diabetes in the NHANES Population Age 50+,Alexander C et al. Diabetes 2003;52:1210-1214,25%,20%,15%,10%,5%,0%,No MS/No DM,8.7%,13.9%,7.5%,19.2%,MS/No DM,
6、DM/No MS,DM/MS,% of population = 54.2% 28.7% 2.3% 14.8%,CHD Prevalence,Schillaci G. JACC. 2004; 43:1817-1822,代谢综合征与心血管危险,Ml and Microvascular End Points: Incidence by Mean Systolic BP and HbA1c Concentration,Ml,Microvascular and points,Ml,Microvascular and points,50,40,30,20,10,0,80,60,40,20,0,Adjus
7、ted incidence per 1000 person-yr (%),110,120,130,140,150,160,170,5,6,7,8,9,10,11,Updated mean systolic BP (mmHg),Updated mean HbA1c concentration (%),Adjusted incidence per 1000 person-yr (%),Adler Al et al. BMJ 2000;321:412-419,Stration IM et al. BMJ 2000;321:405-412,MetS和DM患者血脂异常特征,游离脂肪酸 TG HDL-C
8、VLDL-C 小而密LDL颗粒 氧化LDL-C 餐后高脂血症,Male,Gender-adjusted,Female,Reduced risk with small, dense LDL,0.1,Relative risk for myocardial infarction,1,10,Increased risk with small, dense LDL,Small, dense LDL increases cardiovascular risk,UKPDS Stepwise Selection of Risk Factors* in Patients with Type 2 Diabete
9、s,Variable LDL-C HDL-C Hemoglobin A1c Systolic Blood Pressure Smoking,P Value 0.0001 0.0001 0.0022 0.0065 0.056,Coronary Artery Disease (n=280),Position in Model First Second Third Fourth Fifth,*Adjusted for age and sex. Turner RC et al. BMJ 1998;316:823-828.,Mangaging overweight in type 2 diabetics
10、,Effective weight management is the first step in treating type 2 diabetes,Weight loss (kg) in first 12 months,Lean MEJ et al., Diabet Med, 1990;7:228-233,Good glycemic control is not enough,UKPDS,GOOD GLYCEMIC CONTROL,MICROVASCULAR COMPLICATIONS Significant reductions,MACROVASCULAR COMPLICATIONS No
11、 significant effect,PROACTIVE Study,Sept. 2005, 欧洲糖尿病会议,Pioglitazone vs Placebo,ACCORD Study Action to Control Cardiovascular risk in Diabetes,Prisant LM. J Clin Pharmacol 2004; 44(4):423-430,HbA1c: 6.0% vs 7.0-7.9%,糖尿病患者降压治疗临床试验, SHEP ALLHAT SYST-EUR HOPE CAPPP HOT NORDIL RENAAL STOP-2 PRIME INSIGH
12、T LIFE UKPDS,Major cardiovascular events (per 100 patients-years) in all treated hypertensive and in hypertensive patients with diabetes in relation to target blood pressures of 90. 85, and 80 mm Hg.,HOT Study: Results in Patients with DM,Effect of Intensive vs Moderate Antihypertensive Treatment on
13、 Stroke Incidence in Diabetic Normotensives,Intensive Moderate Achieved BP (mmHg) 128/75 137/81 Stroke (%) 1.7 5.4,Schrier et al., Kidney Int 2002; 61:1086,CHD Prevention Trials with Statins in Diabetic Subjects Subgroup Analyses,Primary Prevention AFCAPS/TexCAPS Secondary Prevention CARE 4S LIPID 4
14、S-Extended,CHD Risk Reduction (overall),Drug,No.,Lovastatin Pravastatin Simvastatin Pravastatin Simvastatin,43% 25% (p=0.05) 55% (p=0.002) 19% 42% (p=0.001),37% 23% 32% 25% 32%,239 586 202 782 483,CHD Risk Reduction (diabetes),Study,Adapted from Downs JR et al. JAMA 1998;279:1615-1622; Goldberg RB e
15、t al. Circulation 1998;98:2513-2519; Pyrl K et al. Diabetes Care 1997;20:614-620; The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. N Engl J Med 1998;339:1349-1357; Haffner SM et al. Arch Intern Med 1999;159:2661-2667.,Trials with Fibrates in Patients with Diabete
16、s,FIELD Study Fenofibrate Intervention and Event Lowering in Diabetes,Mazzone T. Am J Cardiol 2004;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 1.81 mmol/L,Steno-2 Study Multifactorial Intervention and Cardiovascular Disease in Patients with Type 2 Diabetes,Grade P, et al.
17、N ENGL J MED 2003;348:383-393,Steno-2: Intensive Therapy,NEJM 2000; 342:905-912,Basic Intervention,脂肪摄入30% 饱和脂肪酸摄入10% 运动 3035次/w ACEI or ARB 多种维生素 Aspirin,Pharmacology Intervention,降糖 metformin gliclazide metformin + gliclazide 降压 thiazide ACEI or ARB + CCB -blocker 降脂 statins,Steno-2: Treatment Goa
18、ls,Variable Conventional Intensive Therapy Therapy SBP (mmHg) 140 130 DBP (mmHg) 85 80 Hba1c (%) 6.5 6.5 TC (mg/dl) 190 175 TG (mg/dl) 150 150,Steno-2 Change in Clinical Variables at the End of the Study,Variable Conventional Intensive p Therapy Therapy SBP (mmHg) -33 -142 0.001 DBP (mmHg) -82 -122
19、0.006 Carbohydrates(%) 4.80.9 9.30.9 0.001,FPG (mg/dl) -1811 -528 0.001 HbA1c (%) 0.2 0.3 -0.50.2 0.001 TC (mg/dl) -37 -504 0.001 LDL-C (mg/dl) -136 -475 0.001 TG (mg/dl) 943 -4114 0.015,Steno-2 Study: Composite End Point,Grade P et al. N Engl J Med 2003;348:383-393,Primary composite end point (%),60,50,40,30,20,10,0,0,12,24,36,48,60,72,84,96,Months of follow-up,Hazard ratio = 0.47 (95% Cl 0.24, 0.73) P = 0.008,Conventional Therapy,Intensive therapy,小 结,T2DM患者有多重心血管危险因素集聚， 是心血管高危人群。 T2DM治疗的主要目标应 该转移到预防或延缓心血管病事件。在改善生 活行为的同时，积极有效地实施降压、降脂和 降糖综合措施，是控制糖尿病患者心血管危险 的主要治疗策略。,